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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423972
Report Date: 08/04/2025
Date Signed: 08/04/2025 01:01:07 PM

Document Has Been Signed on 08/04/2025 01:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WHITE'S LOVE & CARE RESIDENTIAL ELDERLY HOME INCIIFACILITY NUMBER:
336423972
ADMINISTRATOR/
DIRECTOR:		JACQUELYN J. WHITEFACILITY TYPE:
740
ADDRESS:24068 RISTRAS LANETELEPHONE:
(951) 691-8309
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY: 6CENSUS: 1DATE:
08/04/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:09 AM
MET WITH:Licensee, Jacqueline WhiteTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced Plan of Correction (POC) Visit. LPA met with Licensee, Jacqueline White and her spouse who was informed of the purpose of the visit. LPA conducted a walk through, interviews, and records review in order to verify completion of POC’s.

The following deficiencies were not corrected by the POC due date nor at the time of the visit. Civil Penalties are being assessed and will continue to accrue until the POC has been submitted:

Deficiency cited under CCR Title 22 section 87205 Accountability of Licensee Governing Body for the licensee WHITE'S LOVE AND CARE RESIDENTIAL ELDERLY HOME INC being in a status of suspension with the Franchise Tax Board (FTB). POC was to contact the FTB and obtain proof of agreement to bring the incorporation into good standing. On 6/19/2025 the licensee met with Department staff in office and agreed to submit the POC by the POC due date 06/20/2025. On 07/24/2025 LPA spoke with the licensee’s husband who stated their tax preparer would be sending proof via email. No further proof has been received for the POC.

NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WHITE'S LOVE & CARE RESIDENTIAL ELDERLY HOME INCII
FACILITY NUMBER: 336423972
VISIT DATE: 08/04/2025
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During today’s visit LPA was presented with a signed letter from the licensee's CPA showing the taxes will be filed, however there is no proof of contact and agreement with the FTB at this time. Therefore, the POC was not met and civil penalties are being assessed in the amount of $100 per day for (21) days from 07/14/2025 to 08/03/2025.

Deficiency cited under CCR Title 22 section 87412 Personnel Records for the licensee not having a copy of their LIC503 Health Screening and TB test. POC was to submit proof of the health screening and TB test by 07/10/2025. The Licensee and their spouse stated they would get their TB test done by today and send proof to LPA. Therefore, the POC was not met and civil penalties are being assessed in the amount of $100 per day for (21) days from 07/14/2025 to 08/03/2025.

Deficiency cited under Health and Safety Code section 1569.605 for having no copy of the facility’s liability insurance on file for review. The POC was to submit proof of insurance by 07/04/2025. On 07/24/2025, the licensee’s spouse stated they would be purchasing the insurance and would be sending a copy to the LPA. During today's visit LPA was informed by the Licensee and their spouse that they have not yet purchased the insurance plan and would do so today and send LPA proof. Therefore, the POC was not met and civil penalties are being assessed in the amount of $100 per day for (21) days from 07/14/2025 to 08/03/2025.

Deficiency cited under Title 22 section 87458(c)(5) Medical Assessment for R1’s LIC602 Physician's Report not having accurate ambulatory status and being altered. The POC was to obtain outside resource training for staff and administrator on maintaining accurate records by 07/30/2025.

NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WHITE'S LOVE & CARE RESIDENTIAL ELDERLY HOME INCII
FACILITY NUMBER: 336423972
VISIT DATE: 08/04/2025
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LPA was informed that the training was done by the former administrator, however the documentation was unable to be located at the time of the visit. Therefore, the POC was not met and civil penalties are being assessed in the amount of $100 per day for (4) days from 07/31/2025 to 08/03/2025. The licensee was advised that civil penalties will continue to accrue at the rate of $100 a day until the POC

Deficiency cited under Title 22 section 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities for absence of supervision of at least (10) minutes on 06/30/2025. The POC was to have the licensee submit a written statement showing the termination date for S1 by 07/25/2025. During today's visit, the Licensee confirmed today was S1's last day but did not have documented proof of the termination. The Licensee did not have a copy of staff schedule showing coverage now that S1 has been terminated. Therefore, the POC was not met and civil penalties are being assessed in the amount of $100 per day for (10) days from 07/26/2025 to 08/03/2025.

The licensee was advised that civil penalties will continue to accrue at the rate of $100 a day until the POC's are met and received. An exit interview was conducted with the Licensee and their spouse where this report, LIC421FC Failure to correct Forms, and appeal rights were reviewed and provided.

NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
LIC809 (FAS) - (06/04)
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