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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881051
Report Date: 09/21/2021
Date Signed: 09/21/2021 10:25:22 AM

Document Has Been Signed on 09/21/2021 10:25 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:PACIFIC PINESFACILITY NUMBER:
361881051
ADMINISTRATOR:ACERETO, RAMONFACILITY TYPE:
740
ADDRESS:217 N. GROVE ST.TELEPHONE:
(909) 801-1133
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY: 6CENSUS: 4DATE:
09/21/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Ramon AceretoTIME COMPLETED:
10:25 PM
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
Licensing Program Analyst (LPA) Elecia Weathersby conducted an announced case management visit in order to increase the capacity per licensee request. LPA Weathersby met with Licensee Ramon Acereto and Administrator Nancy Foster and explained the purpose of the visit.

Licensee requested for a capacity increase from 6 residents to 10 residents, which includes an increase from 0 bedridden to 2 bedridden, and all residents able to be non-ambulatory. A Fire Clearance was approved on 9/15/20 for 8 non-ambulatory residents and 2 bedridden residents, for a total of 10 residents. Facility sketch on file shows sufficient square footage in the facility and activity rooms to accommodate the requested capacity. LPA Weathersby discussed the facility sketch with Licensee Ramon Acereto, as well as the proposed changes to the capacity of the residential building. The capacity increase was made to change four (4) single occupancy bedrooms to four (4) shared bedrooms. The changes include the following:
ยท Bedrooms 1, 2, 3, 4 to increase capacity from 4 residents to 8 residents (4 single rooms changing to shared rooms)

LPA Weathersby toured the interior/exterior of the residential building and visually inspected the proposed shared rooms. LPA Weathersby confirmed that all identified shared rooms are large enough to accommodate the required furniture for two residents without inhibiting movement into and throughout the rooms. LPA Weathersby additionally confirmed that there are sufficient bathrooms in the facility (3) to meet Title 22 requirements for ratio of residents to bathrooms.

The physical plant is ready for increase in capacity. LPA Weathersby has notified the Licensee of final capacity increase approval. LPA Weathersby further advised the Licensee that the new license will follow in the mail after capacity increase visit.

An exit interview was conducted where this report was discussed and a copy was provided to Licensee, Ramon Acereto.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Elecia Weathersby
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
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 1