White's Love & Care Residential Elderly Home Incii

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Imaculada Vasquez and Janira Arreola arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted and granted entry by Licensee Jacquelyn J. White. LPA's began inspection with introduction and visit purpose. Upon arrival LPA's learned that there are currently no clients residing at this facility and there is are no caregivers present. Client Records/Incident Reports/Clients Rights Information: LPA's reviewed zero (0)client records. Personnel Records/Training/ Staffing/ Administration: LPA's reviewed zero (0) employee records. Food Service: Food prep areas are clean and organized. Physical Plant and Safety of Environment/Operational Requirements: LPA's toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at a comfortable room temperature. Water temperature measured 113.0 degrees F. There is a locked location for storing laundry soap, cleaning supplies and chemicals in the closet in the laundry room, garage and under the sink. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is no emergency disaster plan available. There are no firearms at this facility. There is one (1) secured fireplace at this facility. There are zero (0) pools at the facility. There is one (1) secured gate that has a self-latching lock located on the northeast side of the house. In the garage LPA's observed two (2) oxgyen tanks. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. Facility has no infection control plan. There is no liability insurance to review during the time of the visit. Medications/Health Related Services/Incidental Medical Services: There are no medications centrally stored. There is a locked cabinet available for medication storage. LPA observed three (3) smoke detectors and one (1) carbon monoxide detectors throughout the facility. There is no emergency and disaster plan available to review. There are two (2) technical violations - There is no current Administrator and no personnel records on site. At the time of the visit, the facility has (3) adults residing in the home, (1) person Person #1 (P1) is not fingerprint cleared. Therefore, the facility is being cited and applicable civil penalties are being assessed in the amount of $500. Pursuant to Title 22 of The California Code of Regulations Division 6, there are two (2) Technical violations, seven (7) deficiencies observed, and civil penalties are being assessed. An exit interview was conducted, this LIC 809 was reviewed with and a copy of this report was provided to Licensee Jacquelyn J. White.the state’s words, verbatim · CDSS document, Mar 18, 2026

The state marks this report as 9 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Case Management - Health Checks

On 10/21/2025, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a health and safety visit. Staff Anbra and Renee Oliver were informed of the purpose of the visit. Licensee Jacquelyn White was contacted over the phone and also informed of the purpose of the visit. LPA toured the facility with Staff Anbra and observed the facility has food and operating utilities. During the visit LPA was informed Resident 1 (R1) passed away in the facility on 10/04/2025 and hospice was notified and responded immediately. However, there is no record the facility reported R1's passing to Community Care Licensing (CCL). As a result, a deficiency will be issued. During the tour, LPA did not observe any additional residents residing in the facility and staff and licensee were advised to notify CCL when a new resident is admitted. Licensee was advised to ensure that all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) obtain a criminal record clearance or exemption prior to working, residing or volunteering in the facility as required by the Department. During today's visit no imminent health or safety concerns were observed. An exit interview was conducted and a copy of this report was reviewed with Licensee White along with the Confidential Names list (LIC 811), LIC 809-D, and Appeal Rights, which were all provided to Staff Anbra. A copy of California Code of Regulations, Title 22, Division 6, Chapter 8, regulation 87211 Reporting Requirements were also provided to Staff Anbra for licensee's review.the state’s words, verbatim · CDSS document, Oct 21, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Oct 24, 2025

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This requirement was not met as evidenced by: During a health and visit at the facility, LPA was informed Resident 1 (R1) passed away in the facility on 10/04/2025. However, there is no record the facility reported R1's death to Community Care Licensing. This poses a potential health, safety, or personal rights risk to residents/future residents in care.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: Licensee reported they will conduct a staff training regarding proper reporting requirements listed in CCR, Title 22, Division 6, Chapter 8 regulation 87211 titled Reporting Requirements. POC to be submitted to LPA by close of business on 10/24/2025.

Type of visit: POC

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced Plan of Correction (POC) Visit. LPA met with Licensee's spouse Troy White who was informed of the purpose of the visit. Troy informed the licensee was not available to meet for the visit. LPA conducted a walk through, interviews, and records review in order to verify completion of POC’s. The following deficiency were corrected by the time of the visit. POC was cleared, however the facility is being issued civil penalties for repeated violation: Deficiency cited under Title 22 section 87355(e)(2) for (1) person who was not fingerprinted and (1) person who was not associated to the facility. The POC was to have the licensee associate the staff and get the staff fingerprinted by POC due date of 08/05/2025. During today's visit, LPA verified both staff were fingerprinted and associated to the facility. Therefore, the POC was met and cleared at the time of the visit. This deficiency was cleared, however during the time of today's visit LPA observed another individual Person #1 (P1) who was sleeping at the facility and was not fingerprinted. Therefore, the facility is being issued civil penalty for repeated violation of uncleared adult in the facility who was present over night. Civil penalty of $100 for background clearance is being assessed for (1) day, and repeated violation immediate civil penalty of $250. 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 by the POC due date 06/20/2025. No further information has been received for meet the POC. During today’s visit LPA met with the licensee's spouse who stated that they have not yet obtained any agreement with the FTB. Therefore, the POC was not met and civil penalties are being assessed in the amount of $100 per day from 08/04/2025 to 09/02/2025. 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's spouse stated they got the health screening completed and would fax the screening to the LPA. Therefore, the POC was not met and civil penalties are being assessed in the amount of $100 per day from 08/04/2025 to 09/02/2025. 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. During today's visit LPA was informed by the Licensee's spouse that they have not yet purchased the insurance plan. Therefore, the POC was not met and civil penalties are being assessed in the amount of $100 per day from 08/04/2025 to 09/02/2025. 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's husband stated S1 was terminated however was not documented for the POC. Therefore, the POC was not met and civil penalties are being assessed in the amount of $100 per day from 08/04/2025 to 09/02/2025. 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.the state’s words, verbatim · CDSS document, Sep 3, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Sep 4, 2025

(e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:(2) Obtain a California clearance or a criminal record exemption...This requirement was not met as evidenced by: Based on interview,record review, and observation P1 did not have a fingerprint clearance to care for, and be theft alone with R1. This poses an immediate health safety, or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: The licensee agreed to remove P1 for the facility, and obtain a clearance prior to P1's return to the facility. P1 was immediately escorted out of the facility. The licensee agreed to submit an update LIC500 showing coverage at all times by cleared and transfered staff to care for R1. LIC500 is due by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced Case Management Visit. LPA met with Licensee, Jacqueline White and her spouse who were informed of the purpose of the visit. LPA conducted a walk through, interviews, and records review. Upon arrival at 10:09am LPA was greeted and granted entry by Person #1 (P1). LPA observed P1 and Resident #1 (R1) where present in the home. Interview with P1 revealed they supervise and change R1. P1 stated they just moved into the facility with Staff #1 (S1), and stated they have not been fingerprint cleared. S1 was interviewed over the phone who confirmed P1 watches R1 when they are not present. LPA met with the licensee's spouse who stated that they thought P1 was fingerprinted. The licensee's spouse is not fingerprinted. At 10:22am LPA informed at this time there are no fingerprinted individuals present to care for R1. The licensee's spouse left to inform the licensee to come and care for R1. The Licensee arrived at 10:58am and agreed to stay with R1 until S1 arrives at the facility. P1 was escorted off the premises. S1's fingerprint clearance was verified with the regional office, however they are not associated to the facility. Therefore, fingerprint clearance violations for lack of clearance and transfer are being cited with a civil penalty of $100 per individual. An exit interview was conducted with the Licensee, Jacqueline White where this report, LIC809-D page, and appeal rights were reviewed and provided.the state’s words, verbatim · CDSS document, Aug 4, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Aug 5, 2025

(e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:(2) Obtain a California clearance or a criminal record exemption...This requirement was not met as evidenced by: Based on interview,record review, and observation P1 did not have a fingerprint clearance to care for, and be theft alone with R1. This poses an immediate health safety, or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Aug 4, 2025

Plan of correction: The licensee agreed to remove P1 for the facility, and obtain a clearance prior to P1's return to the facility. P1 was immediately escorted out of the facility. The licensee agreed to submit an update LIC500 showing coverage at all times by cleared and transfered staff to crae for R1. LIC500 is due by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(3) · Plan of correction due date: Aug 5, 2025

(e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility (3) Request a transfer of a criminal record clearance...This requirement was not met as evidenced by: Based on observation, interview and record review S1's background clearance was not transfered to the facility roster. This poses an immediate health safety, or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Aug 4, 2025

Plan of correction: The licensee agreed to transfer S1's clearance to the facility roster and submit proof by the POC due date.

Type of visit: POC

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. 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. 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.the state’s words, verbatim · CDSS document, Aug 4, 2025

Allegation investigated: The facility is without water service.

Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Peraldi met with Administrator, Armond Hagan and explained the reason for the visit. On 08/03/2022, the Riverside Adult and Senior Care Regional Office (RO) received a complaint regarding an allegation that the facility was without water service. The complaint alleged that due to non-payment, the facility water was turned off 08/01/2022. Continued on LIC 9099-C. Substantiated On 08/04/2022, from 12:05pm to 2:05pm, Licensing Program Analyst (LPA) Yolanda Delgado conducted an unannounced visit to the facility to initiate the investigation into the allegation listed above. LPA Delgado met with the Administrator Jacquelyn White and explained the purpose of the visit. During the visit, the LPA toured the facility, verified running water, interviewed one staff and five residents, and requested and obtained copies of pertinent documentation. The LPA determined further investigation was needed prior to issuing findings. The Department’s investigation revealed that on 08/02/2022 at 4:30pm, it was reported that a hospice staff could not give a bed bath to Resident #1 (R1) because there was no running water in the home. At 6:15pm, the Long-Term Care Ombudsman (LTCO) visited the facility and verified that there was no running water in the house. Staff #1 (S1) stated the Administrator’s husband was on his way to the water company to pay the bill. The LTCO called the Administrator’s husband who confirmed he was trying to get the payment taken care of by water company. The LTCO asked him to purchase extra water to ensure all five residents had enough water for toileting, bathing, cooking of food, drinking and emergencies. The Administrator’s husband stated he would purchase extra water, and that the water service should be back on that night. S1 texted the LTCO at 7:10pm and stated that running water was not turned back on, but the Administrator’s husband had purchased extra water for the home. On 08/03/2022, the LTCO visited the facility at 9:45am and inquired if the water was turned back on. The Administrator stated the water had not been turned back on and they were calling the water company. The LTCO called the facility at 6:33pm and spoke with the Administrator who stated the water was still not turned back on. The Administrator confirmed that she was using extra water purchased for the residents, still no running water in the home. On 08/04/2022, while conducting the initial complaint visit, LPA Delgado verified the facility had running water. Based on the Department’s investigation, the licensee failed to pay the water bill which resulted in the water service being turned off. Interviews with the Administrator, Administrator’s husband, and S1 confirmed the facility was temporarily without water service due to non-payment. Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued. On 08/04/2022, from 12:05pm to 2:05pm, Licensing Program Analyst (LPA) Yolanda Delgado conducted an unannounced visit to the facility to initiate the investigation into the allegation listed above. LPA Delgado met with the Administrator Jacquelyn White and explained the purpose of the visit. During the visit, the LPA toured the facility, verified running water, interviewed one staff and five residents, and requested and obtained copies of pertinent documentation. The LPA determined further investigation was needed prior to issuing findings. The Department requested copies of R1’s records including Centrally Stored Medication Record (CSMR), Medication Assistance Record (MAR), Hospice Care Plan, and Physician Report. None of the records were provided to the Department. The Department left several messages requesting the documents and additional information, however, no response was received from the facility. Interviews conducted revealed Staff #1 (S1) stated that the medications were given as prescribed and documented on the MAR. However that information conflicts with concerns found through other interviews where the medication was observed to not be stored in original containers and it was questionable if medication was given as prescribed due to disorganization of the medication administration procedure. Due to no records being made available to review, the Department was unable to find sufficient evidence to prove R1’s medications were not given as prescribed. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, Jul 26, 2025 · control 18-AS-20220803103955

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jul 26, 2025

87468.1(a)(2) Personal Rights of Residents...(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful...This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when the facility’s water service was turned off due to non-payment of the utility bill, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 26, 2025

Plan of correction: The licensee submitted payment for the water bill, and water service to the facility was restored. POC cleared.

Allegation investigated: Absence of staff supervision

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with Staff, Aidan Hagan who was informed of the purpose of the visit. LPA conducted interviews, conducted a walk through, and conducted records review. It was alleged an “Absence of staff supervision” occurred at the facility where no staff were present on 06/30/2025 to supervise residents.Staff #1 (S1) and Staff #2 (S2) were interviewed and revealed they were both at the facility on 06/30/2025. S1 and S2 alleged S2 was in the restroom when S1 left the facility. Screen captured image from a location app verified S1’s departure time from the facility was 1:36pm. Substantiated S2 then revealed they heard someone knock on the front door when they were in the restroom, which was later answered by Staff #3 (S3). Screen captured image of S3’s location app showed they arrived at the facility at 1:47pm. S2 revealed after coming out of the restroom, S2 left out the front door. S2 did not have any proof of S2’s arrival or departure to the facility. Interview with Staff #3 (S3) was attempted in person and over the phone, however they were unavailable for interview. An interview with a confidential witness #1 (W1) was corroborated by police body camera footage and incident report. The footage shows W1 arrived to the facility at 1:36pm, where they did not receive a response until 1:46pm when S3 arrived at the facility. W1 visits Resident #1 (R1)’s room located next to the front door of the facility. A tour of the home is conducted and S3 is then questioned on who was with the facility residents prior to their arrival. S3 states S1 had just left through the front door when W1 was in R1’s room. However, W1 revealed in both footage and interview that they did not hear anyone leave through the front door. S1 was called immediately at 2:02pm, S1 informs they had left the facility 30 minutes prior, contradicting S3’s statement that S1 had just left. S1 then states S2 was at the home when they left, again contradicting S3’s statements that S1 was present last. After contacting S1, S3 changed their statement stating that S2 was present prior to their arrival, not S1. LPA attempted to interview R1 and R2, however they were not alert or oriented to questions asked by the LPA. Therefore, based on interviews, records review and observation the allegation that there was an absence of staff supervision on 06/30/2025 is substantiated. The preponderance of evidence standard has been met, therefore 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.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 18-AS-20250707095241

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 25, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)…residents…have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers… to meet their individual needs. This requirement was not met as evidenced by: Based on interview and record review, there were no staff supervision for at least 10 minutes on 06/30/2025. This poses an immediate health safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: The licensee's spouse agreed to have the licensee submit a written statement showing terminiation date for S1 by the POC due date. The licensee's spouse agreed to hire a replacement for S1 and submit an LIC500 showing staff coverage at all times.

Allegation investigated: Resident documents are altered and incomplete.

*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 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.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 18-AS-20240306094623

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87456(c)(5) · Plan of correction due date: Jul 30, 2025

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: 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.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: 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.

Type of visit: POC

Licensing Program Analyst (LPA) Janira Arreola and Licensing Program Manager (LPM) Carolyn Tuba conducted an unannounced Plan of Correction (POC) Visit. LPA met with Administrator, Armand Hagan, who was informed of the purpose of the visit. LPA contacted the licensee's husband during the visit. LPA conducted a walk through, interviews, and records review in order to verify completion of POC’s from visits conducted on 06/11/2025 and 07/03/2025. The following deficiencies were corrected by the POC due date. The POC's were cleared at the time of the visit: Deficiency cited under CCR Title 22 section 87411 Personnel Requirements - General for the licensee not having their CPR and first aid certification available for review. POC was to submit proof of the certification by 07/10/2025. During the visit LPA reviewed records and contacted the licensee's husband and verified that the licensee completed the training today on 07/14/2025. Therefore, the POC was met and cleared at the time of the visit. 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 07/07/2025 LPA spoke with the licensee’s husband who stated their tax preparer would be sending proof via email. No further proof was received for the POC. During today’s visit LPA contacted the licensee's husband who stated that they have not been able to obatin proof from the FTB Therefore, the POC was not met and civil penalties are being assessed in the amount of $100 per day for (11) days from 07/03/2025 to 07/13/2025. The licensee was advised that civil penalties will continue to accrue at the rate of $100 a day until the POC is met. 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. During the visit LPA reviewed records and contacted the licensee's husband who stated they will go to get the LIC503 completed by today. 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. During the visit LPA reviewed records and contacted the licensee's husband stated that they would be obtaining the insurance tomorrow. Deficiency cited under Health and Safety Code section 1569.695(a) for not having an up to date LIC610 Emergency and Disaster Plan on file. The POC was to submit proof of a revised plan by 07/10/2025. During the visit LPA reviewed records and spoke to the administrator who stated they would be completing it today. Deficiency cited under Health and Safety Code section 1569.695(c) for not having a documented disaster drill within the last (3) months. The POC was to submit documentation for a disaster drill by 07/10/2025. During the visit LPA reviewed records and spoke to the administrator who stated they would be completing this by tomorrow. Therefore, the POC's were not met and civil penalties are being assessed in the amount of $100 per day for (3) days from 07/11/2025 to 07/13/2025 per violation. The licensee was advised that civil penalties will continue to accrue at the rate of $100 a day until the POC is met. An exit interview was conducted with the staff, Armond Hagan where this report, LIC421FC Faliure to correct Forms, appeal rights, and Clearance Letters were reviewed and provided. *LPA and LPM were off site to prepare this report from 10:44am to 12:30pm.the state’s words, verbatim · CDSS document, Jul 14, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Janira Arreola and Licensing Program Manager (LPM) Carolyn Tuba conducted an unannounced Case Management Visit. LPA met with Administrator, Armond Hagan Jr., who was informed of the purpose of the visit. LPA contacted the licensee's husband during the visit. LPA conducted a walk through, interviews, and records review. During the visit wit was revealed that (1) resident had expired and discontinued medications that were not disposed of. LPA also requested a prior staff's file who had worked at the facility per the Administrator and the Licensee's husband (7) months ago. The administrator was able to produce some documentation for the staff but the file was incomplete for the prior staff member. Therefore the facility was cited for these violations and a plan of correction was created with the Administrator. An exit interview was conducted with the Administrator where this report, the appeal rights and the LIC809-D page was reviewed and provided. *LPA and LPM were off site to prepare this report from 10:44am to 12:30pm.the state’s words, verbatim · CDSS document, Jul 14, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(i) · Plan of correction due date: Jul 21, 2025

(i) Prescription medications...not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record... This rerquirement was not met as evidenced by: Based on interview and observation, the licensee di not ensure the medications were disposed for one resident. This poses a postential health saftey or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 14, 2025

Plan of correction: The administrator agreed to destroy the medications and submit a record described in the cited section by the POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(h) · Plan of correction due date: Jul 28, 2025

(h) All personnel records shall be retained for at least three (3) years following termination of employment. This requirement was not met as evidecned by: Based on interview and record review the licensee did not have (1) staff's file who had stopped working at the facility (7) months prior. This poses a potential health saftey or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 14, 2025

Plan of correction: The licensee agreed to submit training conducted for the licensee and administrator for record keeping by the POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced Case Management Visit. LPA met with Administrator, Armond Hagan, who was informed of the purpose of the visit. LPA later met with Staff, Aidan Hagan. LPA made (3) attempts to contact the licensee during the time of the visit, however no response was received. LPA conducted a walk through, interviews, and records review. LPA conducted a health and safety check on the resident's at the time of the visit. LPA observed (2) residents in care and (2) cleared staff present at the time of the visit. No immediate health or safety issues were observed. A file review revealed annual conducted on 02/22/2024, and continued on 02/26/2024 had uncleared deficiencies that were verified at the time of the visit. Citation for uncleared adults observed 02/22/2024 was issued. During today's visit LPA did not observed any uncleared adults in the facility, therefore the deficiency was cleared. Deficiency was issued for medications that did not have a stop of discontinuation order on file for the resident. LPA reviewed the medications during the time of the visit and found all medications accounted for with doctor's orders and on medications lists. Therefore, this deficiency was also cleared at the time of the visit. Deficiency was cited for medications being stored in weekly pill boxes and outside their originally received containers. During today's visit LPA observed the resident medications in their originally received containers. Therefore the deficiency was cleared. Deficiency was issued for the prior administrator and licensee Jacqueline White not having their CPR and first aid certification available for review. LPA reviewed the file for the licensee and found no CPR certificate on file. Therefore a deficiency was issued. Deficiency was issued for LIC503 Health Screening and TB test for the previous administrator and licensee, Jacqueline White. LPA requested the file for the licensee and found no LIC503 documented for the licensee. Therefore a deficiency was issued. Deficiency was issued for the facility not having a copy of their currently liability insurance. During the visit LPA requested a copy of the facility's liability insurance and found no liability available for review at the time of the visit. Therefore a deficiency was issued. Deficiency was cited for the facility not having an emergency and disaster plan on file. During the visit the LPA reviewed the facility's emergency and disaster plan which revealed the plan did not meet the Title 22 requirements. The licensee must update the plan. New deficiency was cited for the licensee to update the emergency plan. Deficiency was cited for the facility not conducted a quarterly fire drill. during the visit LPA reviewed the last fire drill and found no documented fire drill at the time of the visit. Therefore a deficiency was issued. An exit interview was conducted with staff, Aidan Hagan where this report and deficiency pages, and appeal rights were reviewed and provided. *LPA was off site from 12:05pm to 1:49pm in order to prepare today's report.the state’s words, verbatim · CDSS document, Jul 3, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: Jul 10, 2025

87411 Personnel Requirements - General (c) All RCFE staff...(1)...providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidenced by: Based on interview the licensee (prior administrator) and (1) current staff do not have CPR and first aid training. This poses a potential health saftey or personal rights risk.the state’s words, verbatim · CDSS document, Jul 3, 2025

Plan of correction: The administrator agreed to obatin training for the licensee and staff and send proof by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(f) · Plan of correction due date: Jul 10, 2025

(f)...personnel, including the licensee and administrator, shall be...physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening...performed by a physician... A report shall be...signed by the examining physician...This requirement is not met as evidenced by: Based on interview and record review, the licensee (prior administrator) did not have a health screening on file to review during the visit. This poses a potential health safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 3, 2025

Plan of correction: The administrator agreed to submit a signed copy of a LIC503 conducted by a physician and submit proof by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.605 · Plan of correction due date: Jul 4, 2025

On and after July 1, 2015, all residential care facilities for the elderly...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...This requirement is not met as evidenced by: Based on interview and record review, the facility did not have proof of liability insurance to inspect during the visit. This poses an immediate health saftey or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 3, 2025

Plan of correction: The administrator agreed to submit proof of liability insurance by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.695(a) · Plan of correction due date: Jul 10, 2025

§1569.695 Emergency Plans (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 requirment was not met as evidenced by: Based on interview and record review, the emergency plan does not include the requirements in HSC 1569.695 and needs to be updated. This poses a potential health safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 3, 2025

Plan of correction: The administrator agreed to submit an updated LIC610 in complaince with the section cited by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(c) · Plan of correction due date: Jul 10, 2025

§1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift...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 requirment was not met as evidenced by: Based on interview and record review the facility did not conduct a quarterly fire drill. This poses a potential health saftey or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 3, 2025

Plan of correction: The administrator agreed to conducted and document an emergency drill and submit proof by the POC due date.

Type of visit: POC

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced Plan of Correction (POC) Visit. LPA met with Administrator, Armond Hagan, and later met with Staff, Aidan Hagan who were informed of the purpose of the visit. LPA made (3) attempts to contact the licensee during the visit but no response was received. LPA conducted a walk through, interviews, and records review to verify the POC from visits conducted on 06/11/2025 and 07/01/2025. The following deficiencies were corrected by the POC due date. The POC's were cleared at the time of the visit: Deficiency cited under California Code of Regulations (CCR) Title 22 section 87202 Fire Clearance for the facility exceeding the capacity for residents who are bedridden. The licensee agreed to have the resident relocated and apply for an increase in their bedridden status to the local fire department by POC due date of 07/02/2025. The Department received copy of 30- day eviction notice for the bedridden resident, and proof of appointment with the local fire jurisdiction. Therefore, the POC was met and cleared at the time of the visit. Deficiency cited under CCR Title 22 section Maintenance and Operation 87303 for the facility smoke detectors not having batteries. The staff replaced the batteries for the smoke detectors on 07/01/2025, and on today's visit 07/03/2025 the smoke detectors were tested and observed to be operational. Therefore, the POC was met and cleared at the time of the visit. Deficiency cited under CCR Title 22 section 87355 Criminal Record Clearance for uncleared adult observed be sleeping over night at the facility with their clothing and personal belongings in a vacant resident room. On 07/01/2025, the uncleared adult was escorted off the premises, and on today's visit 07/03/2025 the uncleared adult was not observed at the facility. LPA observed (2) cleared staff at the facility at the time of the visit. Therefore, the POC was met and cleared at the time of the visit. 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 back 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. LPA received phone communication from the licensee’s husband on 06/20/2025 informing they had called the FTB and left a voicemail message. No further proof was submitted for the POC. During today’s visit LPA attempted to speak with Licensee, Jacqueline White who was unavailable at the time of the visit. The Secretary of State website was checked on today's date which still reflect a status of suspension with the FTB. Therefore, the POC was not met and civil penalties are being assessed in the amount of $100 per day for (12) days from 06/21/2025 to 07/02/2025. The licensee was advised that civil penalties will continue to accrue at the rate of $100 a day until the POC is met. An exit interview was conducted with the staff, Aidan Hagan where this report, LIC421FC Faliure to correct Forms, appeal rights, and Clearance Letters were reviewed and provided. *LPA was off site from 12:05pm to 1:49pm in order to prepare today's report.the state’s words, verbatim · CDSS document, Jul 3, 2025

Type of visit: Case Management - Health Checks

On 07/1/25 Licensing Program Analyst (LPA) Javina George and (2) law enforcement Officials from The Murrieta Police Department conducted an unannounced visit to the facility to conduct a health and safety check. At the time of the visit there was (1) staff and (2) residents present. The licensee was at an appointment and was unable to come to the facility. LPA met with Armond Hagan Jr., administrator The utilities were observed to be operable, along with carbon monoxide detectors. The fire extinguishers were observed to be fully charged with a tag in tact. The facility food supply was observed to be adequate. The passageways were observed to be free of any obstructions. The facility was observed to be clean and odor free. The residents were observed to be asleep inside their bedrooms, wearing hospital gowns. The following health and safety concerns and deficiencies were observed during today's visit: LPA observed for there to be an uncleared adult that may be sleeping overnight at the facility. LPA observed a black suitcase, various articles of clothing and a piece of mail inside the closet in the master bedroom. Per administrator Armond Hagan Jr., the individual is there friend and denied having them live at the facility, or even stay overnight. Armond was informed that the uncleared adult could not be at the facility, in addition to having an outstanding warrant. The uncleared individual left the premises. A citation and civil penalties in the amount of $100 is being assessed. - The facility was granted was a fire clearance for (1) resident, however there (2) bedridden residents in care. civil penalties in the amount of $500 is being assessed. Per administrator Hagan Resident #1 (R1) will be relocated, within the next 24 hours to, and the facility will work to get in compliance and obtain an updated fire clearance. In addition the smoke detectors were observed to be inoperable, $500 immediate civil penalties are being assessed. There was a total of $1,100 worth of civil penalties assessed during today's visit. An exit interview was conducted and a copy of this report, appeal rights, 809D LIC-811 Confidential names list was reviewed and provided to Armond Hagan Jr. administrator.the state’s words, verbatim · CDSS document, Jul 1, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Jul 2, 2025

87202 Fire Clearance (a)All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department.. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department.. (2) Bedridden persons this requirement is not met as there are (2) bedridden residents this poses an immediate health safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: The licensee agrees to relocate R1 by the 5pm on the due date indicated and begin the process a for an updated fire clearance.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(a) · Plan of correction due date: Jul 2, 2025

Maintenance and Operation 87303 (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by: Based on observations, the licensee did not comply with the section cited above by not ensuring all smoke alarms were in working condition. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: The batteries were replaced at the time of LPAs visit therefore no POC is due at this time. However civil penalties are still being assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(b) · Plan of correction due date: Jul 1, 2025

87355 Criminal Record Clearance (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. This requirement is not met as evidenced by: There was (1) uncleared adult with an outstanding on the premises with belongings. This posed an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: The uncleared adult was escorted off grounds, therefore there is no POC due at this time. Civil penalties are still being assessed.

Type of visit: Case Management - Health Checks

On 6/16/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced health and safety visit at the facility. LPA was greeted and granted entry by Caregiver, Aidan Hagan who was informed of the purpose of the visit. Licensee, Jacquelyn White was contacted over the phone and also informed of the purpose of LPA's visit. LPA toured the facility with Caregiver Hagan and did not observe any imminent health or safety concerns. During the visit, LPA observed one (1) staff and two (2) residents present. During the phone call, Licensee was informed a mandatory Non-Compliance Conference has been scheduled with her this Thursday, June 19, 2025, at 9:00 a.m. at the Riverside Regional Office located at 1650 Spruce Street, Suite 200, Riverside, CA 92507, to which Licensee agreed to attend. An exit interview was conducted and a copy of this report was reviewed and provided to Caregiver Hagan.the state’s words, verbatim · CDSS document, Jun 16, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced Plan of Correction (POC) visit. LPA met with Administrator, Armond Hagan, who was informed of the purpose of the visit. LPA conducted a walk through, interviews, and records review to verify the POC from Complaint visit conducted 05/27/2025. 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 California Code of Regulations (CCR) Title 22 section 87217(c) Safeguards for Resident Cash, Personal Property, and Valuables for the licensee and staff of the facility being the Power of Attorney (POA) for Resident #1 (R1). POC was to contact local county resources and obtain proof of referral for a new POA or conservator that is not affiliated to the facility for R1. The POC was date 05/28/2025. LPA received phone communication from the licensee’s husband on 05/29/2025 informing they were calling county resources and attempting to find the right referral for R1 to get a new POA or conservator. During today’s visit it was revealed that the a new POA was found and the documents were going to be notarized today. Therefore, the POC was not met and civil penalties are being assessed in the amount of $100 per day for (14) days from . The licensee was advised that civil penalties will continue to accrue at the rate of $100 a day until the POC is met. An exit interview was conducted where this report along with LIC421FC Civil Penalty Pages for Failure to Correct, Clearance letters, and appeal rights were reviewed and provided to staff, Armando Hagan.the state’s words, verbatim · CDSS document, Jun 11, 2025

Allegation investigated: Licensee is resident's responsible party.

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with Staff, Krista Hagan and met with Administrator, Armond Hagan over the phone who were informed of the purpose of the visit. During the visit, LPA conducted interviews, conducted a walk through, and conducted records review. It was alleged “Licensee is resident's responsible party.” It was alleged the licensee was Resident #1 (R1)’s Power of Attorney (POA). The department attempted to conduct interview with R1 who was not alert or oriented at the time of the interview. LPA attempted to interview the licensee who was not available at the time of the visit. The department conducted (2) staff interviews which revealed that the licensee is the POA for R1. Substantiated POA documents for R1 revealed the licensee is the POA over Financial Management and a facility staff is the POA for Health Care. Emergency Contact Sheet for R1 and LIC602 Physician’s Report revealed the licensee signed as R1’s POA. Facility file review revealed complaint #18-AS-20191201121045 which was substantiated for the licensee being R1’s POA. Therefore, based on interviews and record review the allegation that the licensee was the POA for R1 is substantiated at this time. The preponderance of evidence standard has been met, therefore the above allegation is 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, LIC9099 D page, and appeal rights were reviewed and provided.the state’s words, verbatim · CDSS document, May 27, 2025 · control 18-AS-20231010135218

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87217(d)(2) · Plan of correction due date: May 28, 2025

87217 Safeguards for Resident Cash, Personal Property, and Valuables (d)…no licensee…shall: (2) accept any general or special power of attorney for any such person; This requirement was not met as evidenced by: Based on interview and record review the licensee was the POA for R1 which poses an immediate health saftey or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 27, 2025

Plan of correction: The licensee is to call Adult Protective Services (APS) and initate the process to assist R1 in finding a new POA who is not affiliated with the facility. The licensee is to submit proof of this by the POC due date.

Allegation investigated: Facility staff misued resident fianances. Facility staff are making medical decisions on behalf of the resident.

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with Staff, Krista Hagan and met with Administrator, Armond Hagan over the phone who were informed of the purpose of the visit. During the visit, LPA conducted interviews, conducted a walk through, and records review. It was alleged “Facility staff misused resident finances.” It was alleged the licensee became the Power of Attorney (POA) for Resident #1 (R1) and was in charge of R1’s finances such as their social security income (SSI). The department attempted to conduct an interview with R1 who was not alert or oriented during the interview. LPA attempted to interview the licensee who was not available at the time of the visit. Substantiated *This report has been amended an the updated finding and deficiency can be found on LIC9099 dated 7/24/2025. (2) staff interviews revealed the licensee is the POA for R1 for Financial Management and receives R1’s SSI. (1) administrative staff revealed the licensee currently manages R1’s finances, has access to R1’s bank account, and pays R1’s rent. (1) administrative staff revealed the facility does not have a surety bond or ledger for finances managed for R1. Per California Code of Regulations (CCR) Title 22, the licensee of a facility cannot be designated as a resident’s Power of Attorney. The licensee can be designated by the social security administration as a resident’s payee and must document and account for the funds received. Therefore, based on interviews and records reviews the allegation that the licensee was misusing the resident’s finances is substantiated at this time. It was alleged “Facility staff are making medical decisions on behalf of the resident.” It was alleged the licensee was providing medical consent for R1 for medical procedures. It was alleged R1 was unable to provide consent and that the licensee was R1’s POA. The department attempted to conduct an interview with R1 who was not alert or oriented during the interview. LPA attempted to interview the licensee who was not available at the time of the visit. Interview with (1) administrative staff revealed the licensee was making medical decisions for R1, until they designated another staff member as R1’s POA over Health Care. Interview with (1) confidential witness revealed the licensee provided medical consent and signed medical consent forms for R1. File review revealed POA documents dated 05/07/2024 signed by the licensee designating a staff member as the POA for Health Care. Therefore, based on interviews and records review the allegation that the licensee is providing medical consent for R1 is substantiated at this time. The preponderance of evidence standard has been met, therefore the above allegations are 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 LIC 9099D, and appeal rights were reviewed and provided.the state’s words, verbatim · CDSS document, May 27, 2025 · control 18-AS-20240306094623

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87217(c) · Plan of correction due date: May 28, 2025

87217 Safeguards for Resident Cash, Personal Property, and Valuables (c) Every facility shall account for any cash resources entrusted to the care or control of the licensee… This requirement was not met as evidenced by: Based on interview and record review the licensee appointed themselves to be R1's POA over financial management and does not have a surety bond or ledger of finances management. This poses an immediate health saftey or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 27, 2025

Plan of correction: The licensee is to call Adult Protective Services (APS) and initate the process to assist R1 in finding a new POA who is not affiliated with the facility. The licensee is to submit proof of this by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(7) · Plan of correction due date: May 28, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)...residents in privately operated...facilities...shall have all of the following personal rights: (7) To fully participate in planning their care...according to Health and Safety Code section 1569.80 and involve persons of their choice in this planning. The licensee shall provide necessary information and support... This requirement was not met as evidenced by: Based on interview and record review the licensee appointed themselves as the POA for R1 and appointed a staff as R1's POA for Health care. This poses an immediate health, saftey or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 27, 2025

Plan of correction: The licensee is to call Adult Protective Services (APS) and initate the process to assist R1 in finding a new POA who is not affiliated with the facility. The licensee is to submit proof of this by the POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to conduct a Case Management Visit. LPA met with Krista Hagan met with Administrator, Armand Hagan and Administrative Staff Troy White over the phone who were informed of the purpose of the visit. During the visit, LPA conducted interviews, conducted a walk through, and records review. LPA conducted a record review for the current licensee WHITE'S LOVE AND CARE RESIDENTIAL ELDERLY HOME INC. According to the Secretary of State (SOS) website the incorporation has been suspended by the Franchise Tax Bureau (FTB). The facility was cited and a plan of correction was created. An exit interview was conducted where this report, LIC809D page, and appeal rights were reviewed and provided.the state’s words, verbatim · CDSS document, May 27, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87205(b) · Plan of correction due date: Jun 20, 2025

87205 Accountability of Licensee Governing Body (b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. This requirement was not met as evidenced by: Based on records review the licensee is in a state of suspension with the FTB at this time. This poses an immediate health, saftey, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 27, 2025

Plan of correction: The licensee said she will contact Franchise Tax Board (FTB) & make arrangements to lift suspension. Proof from FTB will be submitted by 6/20/25. Licensee will submit proof governing body is active by 7/11/25. *This deficency has been amended

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that two (2) residents live at this facility. There was one (1) staff member present. The Licensee, Jacquelyn J. White was advised of the annual over the phone. The Caregiver, Ajee Ganner came to conduct and completed the facility tour. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Two (2) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration: LPA reviewed employee records. Two (2) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Bridgette Ramasadi Johnson, Administrator’s certificate expiration date was 04/04/2025. Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a location for sharps in the kitchen. Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 76 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 108.0 degrees F. Laundry is done in the laundry room. There is a locked location for storing laundry soap, cleaning supplies and chemicals in the closet in the laundry room, garage and under the sink. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA dialed the facility’s landline number, which rang and was operable. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There is one (1) secured fireplace at this facility. There are zero (0) pools at the facility. There is one (1) secured gate that has a self-latching lock located on the northeast side of the house. LPA observed emergency supplies and two (2) first aid kits. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that staff had infection control training. Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed that they were dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed four (4) smoke detectors and four (4) carbon monoxide detectors throughout the facility. Pursuant to Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to Caregiver, Ajee Ganner.the state’s words, verbatim · CDSS document, Jan 14, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Annual Continuation

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.the state’s words, verbatim · CDSS document, Feb 26, 2024

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Feb 22, 2024