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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700739
Report Date: 08/24/2023
Date Signed: 08/24/2023 02:48:56 PM


Document Has Been Signed on 08/24/2023 02:48 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:PINES, THEFACILITY NUMBER:
312700739
ADMINISTRATOR:HENRY COLEFACILITY TYPE:
740
ADDRESS:500 W RANCHVIEW DRIVETELEPHONE:
(916) 672-5019
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:142CENSUS: 126DATE:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Henry Cole, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with Administrator Henry Cole during today's inspection. LPA ensured they applied hand sanitizer before entering the facility.

LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 6 resident rooms, medication room, staff area, bathrooms, kitchen, common living spaces, outdoor spaces, activity areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the assisted living side of the facility and the memory care unit with a delayed egress. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete.

LPA reviewed 12 resident files and 6 staff files. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates and training completed. LPA observed a copy of current liability insurance.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
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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