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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700739
Report Date: 10/12/2020
Date Signed: 10/12/2020 02:59:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PINES, THEFACILITY NUMBER:
312700739
ADMINISTRATOR:ROBERTSON, JOHNFACILITY TYPE:
740
ADDRESS:500 W RANCHVIEW DRIVETELEPHONE:
(916) 672-5019
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:142CENSUS: 0DATE:
10/12/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:John RobertsonTIME COMPLETED:
02:30 PM
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Licensing Program Analyst(LPA) contacted the facility via telephone due to COVID-19 and pre-cautionary measures. The purpose of this call is conducting an announced prelicensing visit. LPA spoke to John Robertson, General Manager via facetime. This facility is undergoing a change in ownership.

The fire clearance is for 127 non-ambulatory residents and twelve bedridden residents for a total of 142 residents The assisted living section has forty-five studio with one bathroom apartments, twenty-six one bedroom and one bathroom apartments, two two bedroom and one bathroom apartments, and four two bedroom and two bathroom apartments. All assisted living apartments have kitchenettes. The assisted living side has many common areas, a dining area, a theater, salon, medication room, laundry room that staff use and two laundry room that residents may use, and several outside areas. The memory care unit is enclosed with a delayed egress and it has nine studio apartments and forty six semi-private apartments and all have bathrooms. The memory care apartments do not have kitchenettes. The memory care unit has two enclosed outside courtyards, medication room, salon, dining room, laundry room that only staff have access to, and several common areas for residents. Several topics were discussed during this visit.

LPA waived component III orientation because the administrator has prior working experience operating RCFEs.

This facility meets all regulations. LPA is going to submit this report to the application specialist for final review.

LPA is going to email a copy of this report to Administrator and Administrator is to sign, and email a copy back to LPA.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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