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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530184
Report Date: 11/14/2024
Date Signed: 11/20/2024 09:33:19 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/13/2024 and conducted by Evaluator Beena Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241113114026
FACILITY NAME:PACIFIC PINES ASSISTED LIVING FACILITYFACILITY NUMBER:
365530184
ADMINISTRATOR:ZAMORA, JOELFACILITY TYPE:
740
ADDRESS:5850 N MANZANITA AVETELEPHONE:
(909) 557-5477
CITY:ANGELUS OAKSSTATE: CAZIP CODE:
92305
CAPACITY:15CENSUS: 15DATE:
11/14/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Facility Manager Doug HicksTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Licensee did not ensure facility evacuation plan provides safe temporary accommodations for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to deliver findings on the allegations listed above. LPA Beena Singh met with Facility Manager Doug Hicks and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First Complaint: Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Manager Doug Hicks and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation: Licensee did not ensure facility evacuation plan provides safe temporary accommodations for residents. Staff reported that the facility has two designated evacuation sights in Calimesa. During a recent fire the facility was required to evacuate, and residents were relocated to a motel. No evacuation chair needed, according to the fire department pre-licensing report. According to six out of six residents the motel provides food and accommodation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 56-AS-20241113114026
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ASSISTED LIVING FACILITY
FACILITY NUMBER: 365530184
VISIT DATE: 11/14/2024
NARRATIVE
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Residents stated staff provide supervision at the motel and staff reporting providing supervision to the resident while staying at the hotel, Staff provided day and night supervision while staying at the evacuation site Calimesa motel.
Based on the evidence found during the investigation, LPA Beena Singh found the allegations listed above to be Unsubstantiated.

Unsubstantiated: A finding that the complaints are Unsubstantiated means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Facility Manager Doug Hicks.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2