361881051-2-22-2021-18-AS-STOS-BYGNM7-20210222093441

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881051
Report Date: 02/09/2021
Date Signed: 02/22/2021 09:35:06 AM

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 PINES		FACILITY NUMBER:	361881051
ADMINISTRATOR:	ACERETO, RAMON		FACILITY TYPE:	740
ADDRESS:	217 N. GROVE ST.		TELEPHONE:	(909) 801-1133
CITY:	REDLANDS	STATE: CA	ZIP CODE:	92374
CAPACITY:	6	CENSUS: 0	DATE:	02/09/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Ramon Acereto, Licensee		TIME COMPLETED:	11:30 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	Licensing Program Analyst (LPA), Stephanie Torres, conducted an announced pre-licensing video conference inspection to the facility due to COVID-19. The LPA met with Licensee/Administrator, Ramon Acereto. There are currently no residents in care. Application: The application is for a Residential Care Facility for the Elderly. The fire clearance has been granted for six (6) non-ambulatory residents, of which two (2) may be bedridden. Buildings and Grounds: The home is composed of five (5) bedrooms, two and a half (2 1/2) bathrooms, a utility room (with laundry), a great room (living room), kitchen and dinning area, and a front yard area. The interior/exterior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were tested and operable. There are no pools or other bodies of water located at the home. According to Acereto, there are no weapons stored in the home. Rooms, furniture, beds, mattresses are all in good repair. The bedrooms are completely furnished and privacy is available. The dining and living room areas are clutter free and in good condition. Bathrooms were observed to have non-slip flooring available. The tank-less water heater measured at 120.0 degrees Fahrenheit, which is within regulatory limits. Outdoor areas had sufficient room for activities and leisure. A washing machine and dryer are available and in working order. Storage and Supplies: Activities were observed to be available and in sufficient amount for the requested census. Medications will be stored inaccessible to any unauthorized individuals. Secured areas are available for facility files and resident files. The first aid kit was observed to be available and complete. Cleaning supplies will be stored away in a closet, which is located in the utility room. Linens, and equipment are all in good repair and sufficient for approved census. A Fire extinguisher was available and fully charged. Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 PINES	FACILITY NUMBER: 361881051
	VISIT DATE: 02/09/2021

NARRATIVE

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are in working order. Sharps will be stored in a locked kitchen drawer, available only to authorized individuals.

Forms: The following signs were observed to be posted at the home: Emergency Disaster Plan (LIC 610E), Theft and Loss Policies, Visitors Policy, Personal Rights, and Facility Sketch (LIC 999), Labor Law Information, and the Complaint Information.

The LPA will inform the Centralized Applications Bureau (CAB) the home is ready for licensure. This report was discussed with and a copy provided to Acereto via email.

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2021

LIC809 (FAS) - (06/04)

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