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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880768
Report Date: 01/13/2022
Date Signed: 01/13/2022 10:18:47 AM

Document Has Been Signed on 01/13/2022 10:18 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PINE CREEK CARE SERVICESFACILITY NUMBER:
331880768
ADMINISTRATOR:DAVIS, CHRISFACILITY TYPE:
735
ADDRESS:38203 PINE CREEK PLACETELEPHONE:
(951) 319-6374
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY: 4CENSUS: 2DATE:
01/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Nicole Carpenter, Direct Support StaffTIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Javina George conducted an unannounced Case Management Incident visit. LPA was greeted and granted entry by Direct Support staff Nicole Carpenter. LPA explained the purpose of the visit and met with Nicole. Administrator was available by telephone. The visit is in response to the death of Resident #1 (R1), whom passed away on 1/9/2022.

During LPA's visit, LPA reviewed R1's file and obtained copies of the following: ID/emergency Information form, admission agreement, Physician's reports, resident pre admission appraisal, progress notes, medication records (MARs), Personal property records, weight record, and laboratory paperwork. Additionally, LPA requested a copy of R1s death certificate when it is made available.

During today's visit no deficiencies were cited in regards to this incident.

An exit interview was conducted, and a copy of this report was provided to Nicole Carpenter.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2022
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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