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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
336423972
Report Date:
02/26/2024
Date Signed:
02/26/2024 04:35:54 PM
Document Has Been Signed on
02/26/2024 04:35 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 INCII
FACILITY NUMBER:
336423972
ADMINISTRATOR:
JACQUELYN J. WHITE
FACILITY TYPE:
740
ADDRESS:
24068 RISTRAS LANE
TELEPHONE:
(951) 319-6622
CITY:
MURRIETA
STATE:
CA
ZIP CODE:
92562
CAPACITY:
6
CENSUS:
1
DATE:
02/26/2024
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME BEGAN:
02:50 PM
MET WITH:
Licensee, Jacquelyn White
TIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted a continuation annual visit from 2/22/2024. LPA met with Licensee, Jacquelyn White, who was informed of the purpose of the visit.
The facility does not have an infection control plan for inspection. The facility had PPE supplies observed during the visit. The client file had all required documents, the personnel records and training were not available during the visit to inspect.
All client medication was locked in the kitchen. LPA reviewed client medication and found medication was being kept in pill boxes and discontinuation order for medication was not on file for Resident #1 (R1). The facility also did not have a copy of the liability insurance for inspection. No disaster plan was available during the visit for review and staff interview stated there was no plan on file or training on this plan. The staff was also not able to state the date of the last drill.
The above issues were cited and a plan of correction was created with the licensee. An exit interview was conducted where a copy of this report along with appeal rights, deficiency pages, lic811, and lic9098 were reviewed and provided to the licensee.
SUPERVISOR'S NAME:
Rikesha Stamps
TELEPHONE:
(951) 212-0616
LICENSING EVALUATOR NAME:
Janira Arreola
TELEPHONE:
951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE:
02/26/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
5
Document Has Been Signed on
02/26/2024 04:35 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:
02/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.
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 due to no discontinuation of medication that was not on file for (1) resident which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/18/2024
Plan of Correction
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The licensee agreed to obtain dicontinuation orders from the resident physican and send LPA proof by POC due date
Type B
Section Cited
CCR
87412(f)
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
This requirement is not met as evidenced by:
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 with the licensee/administrtor's and staff's health screening which was not avaible for licensing to inspect during the visit which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/11/2024
Plan of Correction
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The licensee agreed to send the LPA a copy of the health screening by the POC due date.
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 Stamps
TELEPHONE:
(951) 212-0616
LICENSING EVALUATOR NAME:
Janira Arreola
TELEPHONE:
951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE:
02/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/26/2024
LIC809
(FAS) - (06/04)
Page:
2
of
5
Document Has Been Signed on
02/26/2024 04:35 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:
02/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above with the liability insurance that was not avaible for licensing to inspect during the visit which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/04/2024
Plan of Correction
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The licensee agreed to send the LPA a copy of the liability insurance by the pOC due date.
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:
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 based on self admission that training records were not at the facility and were not present to LPA for inspection. The licensee also did not have complete records for staff at the facility for inspection which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/04/2024
Plan of Correction
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2
3
4
The licensee agreed to send the LPA training records for staff by the POC due date.
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 Stamps
TELEPHONE:
(951) 212-0616
LICENSING EVALUATOR NAME:
Janira Arreola
TELEPHONE:
951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE:
02/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/26/2024
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
02/26/2024 04:35 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:
02/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Requirements - General
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above with resident medication that was kept in a weekly pill box which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/11/2024
Plan of Correction
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The licensee agreed to remove this practve and send the LPA a written statment of in-service of new medication procedure to comply with section cited above. This is due by the POC due date.
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 Stamps
TELEPHONE:
(951) 212-0616
LICENSING EVALUATOR NAME:
Janira Arreola
TELEPHONE:
951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE:
02/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/26/2024
LIC809
(FAS) - (06/04)
Page:
4
of
5
Document Has Been Signed on
02/26/2024 04:35 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:
02/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview, the licensee did not comply with the section cited above by not having an emergency diaster plan for the LPA to inspect during the time of the visit which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/04/2024
Plan of Correction
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The licensee agreed to send the LPA a copy of the LIC610 form completed by the POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview, the licensee did not comply with the section cited above with no documented drill conducting within th required timeframe stated above which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/04/2024
Plan of Correction
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4
The licensee agreed to send the LPA a copy of drill conducted by the POC due date. The documentation should comply with the above.
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 Stamps
TELEPHONE:
(951) 212-0616
LICENSING EVALUATOR NAME:
Janira Arreola
TELEPHONE:
951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE:
02/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/26/2024
LIC809
(FAS) - (06/04)
Page:
5
of
5