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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881051
Report Date: 11/24/2021
Date Signed: 11/24/2021 10:36:24 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 PINESFACILITY NUMBER:
361881051
ADMINISTRATOR:ACERETO, RAMONFACILITY TYPE:
740
ADDRESS:217 N. GROVE ST.TELEPHONE:
(909) 801-1911
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY:10CENSUS: 9DATE:
11/24/2021
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Ramon Acereto - CEOTIME COMPLETED:
10:40 AM
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Licensing Program Analysts (LPAs) Anna Bueno and Bernadette Allen met with Chief Executive Officer (CEO) Ramon Acereto to sign an amended complaint report #18-AS-20211109135701 for LIC 9099 dated 11/17/2021. This complaint is on the facility's location on 5850 Manzanita Avenue in Angelus Oaks and this complaint has a finding of unsubstantiated conclusion. An error occurred with the Department's system that caused a failure in capturing the signed completed report on 11/17/2021. LPAs Bueno and Allen and (CEO) Acereto signed this report and amended LIC 9099 was given to (CEO)
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021
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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