<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336423972
Report Date: 07/24/2025
Date Signed: 07/24/2025 07:09:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
03/06/2024 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240306094623
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:
07/24/2025
UNANNOUNCEDTIME BEGAN:
03:27 PM
MET WITH:Staff, Aidan HaganTIME COMPLETED:
07:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident documents are altered and incomplete.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
*The following is an amended report: Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to deliver findings to the above allegation. LPA met with Staff, Aidan Hagan, who was informed of the purpose of the visit. LPA conducted interviews, documented observations, conducted a walk through, and records review.

It was alleged “Resident documents are altered and incomplete.” It was alleged R1’s LIC602 Physician’s Report was incomplete and appeared to be altered by facility staff. The department attempted to conduct an interview with R1 who was not alert or oriented during the interview.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
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 3
Control Number 18-AS-20240306094623
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/24/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Review of R1’s Physician’s Reports dated 03/21/2024 and 10/23/2023 were observed to be complete and signed by a physician. The 03/21/2024 report was observed to have ambulatory status of “Bedridden” circled in pen and then covered partially in whited out. Interview with (3) facility staff revealed they did not know if staff or the resident’s physician had placed white out on the report. Medical records were requested from R1’s attending physician. Plan of Care dated 02/28/2024 revealed R1 is bed bound. Visit Notes from 09/11/2023 R1 follows simple command to reach to side with transfer, requires maximum assist with turning and repositioning, and had a bilateral amputation on both legs which limited mobility.

Therefore, based on observations, interviews, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations Title 22 is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided. Attempt to contact the licensee was conducted and the Licensee's spouse provided information on plan of correction.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20240306094623
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2025
Section Cited
CCR
87456(c)(5)
1
2
3
4
5
6
7
87458 Medical Assessment(c)The medical assessment shall include, but not be limited to:(5)The determination whether the person is ambulatory or nonambulatory…or bedridden as defined in Health and Safety Code section 1569.72. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The licensee's spouse agreed to obtain outside resource training for staff and administrator on mainitain accurate records. This is due by the POC due date.
8
9
10
11
12
13
14
Based on observation and record review the LIC602 for R1 did not accurately reflect R1’s ambulatory status and appeared to be altered or incomplete. This poses a potential health safety or personal rights risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3