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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530184
Report Date: 11/20/2024
Date Signed: 11/20/2024 09:35:02 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
11/12/2024 and conducted by Evaluator Beena Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241112155216
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:
11/20/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Facility Manager Doug HicksTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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9
Staff do not ensure that residents are utilizing the stairs in a safe manner.
Staff do not ensure that the facility is secure and free from wildlife.
INVESTIGATION FINDINGS:
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Second Complaint: 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 allegation, Staff do not ensure that residents are utilizing the stairs in a safe manner.

During interviews with residents, all six residents who were interviewed denied having safety issues in the facility. Residents were happy with safety measures facility takes to keep them safe. Stairs are used only for residents who can walk on their own, but staff supervises them. Staff reported that there is a ramp built at the facility which allows residents to use their wheelchairs or four-wheel walkers. During an evacuation facility staff helped supervise residents.
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-20241112155216
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: 11/20/2024
NARRATIVE
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Second allegation, Staff do not ensure that the facility is secure and free from wildlife.

During interviews with residents, all six residents who were interviewed denied having any issues with wild animals. Residents deny any issues with wildlife sighting at the facility, Staff reported that bins are kept clean and with heavy padlock, so no wild animals have access to food waste bins.

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.
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