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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423972
Report Date: 02/22/2024
Date Signed: 02/22/2024 05:02:46 PM


Document Has Been Signed on 02/22/2024 05:02 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:JACQUELYN J. WHITEFACILITY TYPE:
740
ADDRESS:24068 RISTRAS LANETELEPHONE:
(951) 319-6622
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:6CENSUS: 2DATE:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Facility Representative, Troy WhiteTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Facility representative, Troy White and Administrator and Licensee Jacqueline White, who were informed of the purpose of the visit. At time of visit there were (2) residents and (4) staff present. The facility is a two story home with (4) bedrooms and (2) bathrooms with attached garage. The facility does not have a pool or fire arms. The facility serves elderly ages 60 and above. LPA conducted a tour of the interior and exterior and reviewed facility documents, and conducted staff and resident interviews. The following was observed:
Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. The carbon monoxide detector was located during the time of the visit. Medications, sharp and dangerous items are kept in locked area. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Staffing: During the time of the visit, LPA interviewed staff, and reviewed background clearance. Based on record review and interview it was found that (2) staff who provide care and supervision to residents were not fingerprinted with the department and were present during the visit. A plan of correction was made and removal was confirmed with licensee. A deficiency was cited for the staff and civil penalty was issued in the amount of $500 per staff, totaling $1000. Additionally, licensee was unable to show LPA proof of (1) staff having a valid CPR and First aide card. This deficiency was issue and plan of correction was created with Licensee. Due to time constraints and observation, the facility visit will be continued on a different unannounced date. No other immediate health or safety risks were observed during the time of the visit. An exit interview was conducted with Facility representative, Troy White where this report, along with LIC809-D page, civil penalty form, appeal rights, LIC9098, and a copy of LIC311C was provided to the licensee.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
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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Document Has Been Signed on 02/22/2024 05:02 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above with (2) indivudals who did not have valid department criminal clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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The licensee agreed to remove the inviduals from the premisis and agreed to send the LPA their staffing plan to ensure they have enough they have sufficent staffing to meet the residents needs from qualified cleared staff. This is due by the POC due date.
Type A
Section Cited
HSC
1569.618(c)(3)
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not being able to provide record of a valid CPR and first aide card for any staff on premisis which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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The licensee agreed to send the record of the administrtor's CPR card to the LPA, and send a written statement certifying that they will use the LIC311C to review staff records and for onboarding staff and ensure at least (1) staff on shift has valid CPR and first aide.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2