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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880768
Report Date: 04/25/2024
Date Signed: 04/25/2024 01:54:13 PM

Document Has Been Signed on 04/25/2024 01:54 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PINE CREEK CARE SERVICESFACILITY NUMBER:
331880768
ADMINISTRATOR/
DIRECTOR:		DAVIS, CHRISFACILITY TYPE:
735
ADDRESS:38203 PINE CREEK PLACETELEPHONE:
(951) 319-6374
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY: 4CENSUS: 4DATE:
04/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:FACILITY MANAGER, HOANG TROUNG.TIME VISIT/
INSPECTION COMPLETED:
01:55 PM
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On April 25, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a case management health and safety visit, and met with the Facility Manager. LPA Mixson introduced herself and explained the purpose of the visit.

LPA Mixson toured the facility, along with the Facility Manager and made observations. There were two staff present and three residents at the time of this case management visit. There are no imminent health and/or safety concerns observed at the time of visit. The LPA requested and received pertinent documentation. (Activities schedule).

LPA Mixson did not observed any health and/or safety hazards inside or outside of the facility at the time of this visit. LPA observed the facility utilities to be operating without issue. LPA Mixson assessed the available food and observed there was a variety of food types available for the residents in care. The food supply meets the requirement of a two day supply of perishable foods and a seven day supply of non-perishable foods. The medications were found to be in sufficient supply, locked, and inaccessible to the residents in care.

Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and/or welfare of the residents in care. No deficiencies were observed or cited during today's visit.

An exit interview was conducted and a copy of this report was provided to the Facility Manager.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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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