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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530184
Report Date: 12/23/2024
Date Signed: 12/23/2024 11:54:30 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
09/25/2024 and conducted by Evaluator Renese Howell-Small
COMPLAINT CONTROL NUMBER: 56-AS-20240925153435
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: 13DATE:
12/23/2024
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:House Manager, Doug HicksTIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Facility is violating residents' personal rights
Staff is providing care while under the influence of drugs
INVESTIGATION FINDINGS:
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On 12/23/2024 at 9:05AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA discussed the purpose of the visit with House Manager, Doug Hicks. LPA also interviewed and met with Administrator, Joel Zamora. LPA conducted a brief tour of the facility. The investigation consisted of interviews and record review.

In regards to the allegation of facility is violating residents' personal rights:
LPA interviewed five (5) staff and ten (10) residents. LPA observed some residents in their rooms and in the main kitchen area interacting with each other and staff members. Residents were observed to be talkative, friendly and content. Residents interviewed confirm that they are treated well and get the help that they need. LPA observed four (4) staff providing care, confirmed staff cleaning schedule and observed residents eating breakfast and a staff preparing a hot lunch for residents in care.
The allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
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-20240925153435
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: 12/23/2024
NARRATIVE
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In regards to the allegation of staff is providing care while under the influence of drugs:

LPA interviewed five (5) staff and ten (10) residents. Both staff and residents deny witnessing staff provide care while under the influence of drugs. LPA observed the four (4) staff working at the facility during the visit to be alert, attentive to residents and able to answer LPA's questions clearly and with confidence.

The allegation is UNSUBSTANTIATED.

UNSUBSTANTIATED is defined as The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted where this report LIC9099 and LIC9099C was discussed and a copy was given to House Manager, Doug Hicks.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2