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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530184
Report Date: 12/26/2023
Date Signed: 12/27/2023 11:13:59 AM

Document Has Been Signed on 12/27/2023 11:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 9-14-8201
, CA 95814
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: DATE:
12/26/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Joel Zamora, Lailanie ZamoraTIME COMPLETED:
10:23 AM
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Facility Type: Residential Care Facility for the Elderly
Application Type: Change of ownership
Capacity: 15
Census (if any clients in care): 14
COMP II Participants: Joel Zamora, Lailanie Zamora
Interview Method: Telephone interview

On December 26, 2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.
During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restricted/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Joshua Miller
LICENSING EVALUATOR NAME: Bethany Hunter
LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2023
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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