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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881051
Report Date: 01/29/2026
Date Signed: 01/29/2026 12:35:25 PM

Document Has Been Signed on 01/29/2026 12:35 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PACIFIC PINESFACILITY NUMBER:
361881051
ADMINISTRATOR/
DIRECTOR:		ISHMAEL SIAPCOFACILITY TYPE:
740
ADDRESS:217 N. GROVE ST.TELEPHONE:
(909) 801-1911
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY: 10CENSUS: 10DATE:
01/29/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator Ishmael SiapcoTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarina Ramirez made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator Ishmael Siapco, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (10), a current census of (10). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility does not have a swimming pool or similar bodies of water. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has sufficient indoor and outdoor space for resident activities. Activities consist of puzzles, sing a-longs, and dominoes. The facility is equipped with operating smoke detectors/carbon monoxide alarms, working laundry equipment, and telephone service. Resident’s showers, toilets, and hand washing areas were operating properly. The hot water temperature in two (2) resident bathrooms measured between 110.4 and 112.2 degrees F. Four (4) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, facility license, facility sketch, emergency telephone numbers, personal and resident rights, menu, CCLD complaint poster, and Ombudsman poster.


Continuation on LIC – 809C:
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Sarina Ramirez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PACIFIC PINES
FACILITY NUMBER: 361881051
VISIT DATE: 01/29/2026
NARRATIVE
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Food Service: Facility kitchen and dining area are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps and chemicals were not kept locked and inaccessible to residents in care, deficiency issued.

Care & Supervision: Facility has 24-hour/7days a week care staff. One (1) Facility staff had an expired CPR certificate, technical violation issued.



Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet, one (1) resident's medication was audited and random with discrepancies, deficiency issued.

Record Review: Four (4) Staff files reviewed were observed to be complete, other than Staff #1 (S1) expired CPR certificate. Four (4) Resident files reviewed were observed to be incomplete, deficiency issued. Facility did not have an emergency disaster plan, deficiency issued. Facility has not conducted a disaster drill since December 2024, deficiency issued.

Based on observations and record review technical violations and deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC 809, 809C, 809D, 9102) and appeal right were discussed and a copy was provided to Administrator Ishmael Siapco.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Sarina Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 01/29/2026 12:35 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 01/29/2026 at 11:48 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFIC PINES
FACILITY NUMBER: 361881051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), (interview), or (record review)], the licensee did not comply with the section cited above by not having the drawer obtaining sharps locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2026
Plan of Correction
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Administrator has agreed to provide a training to staff and provide proof with signatures and understanding of the regulation cited to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/29/2026 12:35 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 01/29/2026 at 11:48 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFIC PINES
FACILITY NUMBER: 361881051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by not administering medication per physicians orders and/or not providing signatures when medication to administered to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2026
Plan of Correction
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Administrator has agreed to provide in service training to staff and provide proof to LPA with signatures by POC due date.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2026
Plan of Correction
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Administrator has agreed to obtain a new physician report (LIC602A) for R3, signed 602 for R4, and TB results for R1 and provide proof to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2026


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 01/29/2026 12:35 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 01/29/2026 at 11:48 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFIC PINES
FACILITY NUMBER: 361881051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by not having a disaster plan on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2026
Plan of Correction
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Administrator has agreed to create disaster plan and provide proof to LPA by POC due date
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by not conducting a diaster drill since December 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2026
Plan of Correction
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Administrator has agreed to conduct a disaster drill and continue to do so quarterly Administrator will provide proof of disaster drill to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2026


LIC809 (FAS) - (06/04)
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