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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700739
Report Date: 10/19/2021
Date Signed: 10/19/2021 10:41:15 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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: 116DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:John Robertson, General ManagerTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On, November 19, 2021, at 9am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a required 1 year inspection. LPA met with , General Manager John Robertson and explained purpose of inspection. Prior to initiating the inspection LPA completed COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: mask. Additionally, LPA was screened by the front desk personnel upon arrival.

John and LPA completed the inspection tool questionnaire with no issues or advisories to report.

LPA observed the following:
Administrator certificate is valid. First aid kit fully stocked and ready for emergency use.. Common areas were clean and in good repair.LPA reviewed 6 staff files and 8 resident files. All Staff files had the required Criminal Records Clearance, Proper First Aid and CPR Certificates and are participating in training as required. All residents files had the required signatures for Consent to receive medical treatment, Emergency contact information, Physician's report and residents rights .

To continue see 809 -C...
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: PINES, THE
FACILITY NUMBER: 312700739
VISIT DATE: 10/19/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
As a result of this visit, no deficiencies were cited, per Title 22 Regulations, Division 6.

General Manager shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file in our Regional Office.

Administrator shall submit the listed documents to Licensing later than November 19, 2021.

An exit interview was conducted and a copy of this report was given to John Robertson.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2