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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336423972
Report Date: 11/02/2021
Date Signed: 11/02/2021 10:20:40 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2019 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191008122749
FACILITY NAME:WHITE'S LOVE & CARE RESIDENTIAL ELDERLY HOME INCIIFACILITY NUMBER:
336423972
ADMINISTRATOR:JACQUELYN J. WHITEFACILITY TYPE:
740
ADDRESS:24068 RISTRAS LANETELEPHONE:
(951) 319-6622
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:6CENSUS: 4DATE:
11/02/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jacquelyn WhiteTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was not provided required medical equipment resulting in hospitalization
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Javier Prieto and LPA Lama conducted an unannounced visit to the facility to deliver the finding of the above allegation. LPA met with Jacquelyn White.

The investigation was conducted by the Department. The investigation consisted of file review and interviews with relevant parties. Based upon investigation, there is insufficient evidence to substantiate the allegation of Neglect/Lack of Care & Supervision. It was found that on 10/1/2019, resident 1 (R1) was discharged from the hospital to the facility and arrived without any medical equipment. Several hours after arriving to the facility R1 was observed to require medical attention and was transported back to the hospital. Interviews conducted revealed there was no proof or documentation of medical equipment provided to the facility when R1 arrived.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20191008122749
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 11/02/2021
NARRATIVE
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Based on the information obtained there is not enough evidence to corroborate that resident was not provided required medical equipment resulting in hospitalization. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2