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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530184
Report Date: 03/13/2024
Date Signed: 03/13/2024 12:41:17 PM

Document Has Been Signed on 03/13/2024 12:41 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 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:
03/13/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Joel and Lailanie Zamora, AdministratorsTIME COMPLETED:
12:42 PM
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Licensing Program Analysts (LPA) Anna Bueno conducted an announced pre-licensing inspection of the facility. LPA met with Licensees Joel and Lailanie Zamora who were informed of the purpose of today's visit. There are currently no residents in care.

Application: The application is for a Residential Care Facility for the Elderly. Fire clearance has been granted for fifteen (15) non ambulatory, with rooms having been approved for bedridden residents . Fire inspection was on conducted on December 13,2023 by the San Bernardino County Office of the Fire Marshal.

Buildings and Grounds: The facility is composed of six (6) one-story buildings. Five (5) buildings have two resident bedrooms and bathrooms. One common use building (main lodge) houses the kitchen, dining area, and medication room. The main office is attached to a resident building and the supply closet and laundry room is attached to another resident building. LPA and Licensees toured the interior and exterior of the facility. This facility has no bodies of water. A shaded siting area is available for residents. LPA and Licensees observed that ramps and walkways are free of obstruction. The facility has a working telephone for residents use. LPA and Licensees observed charged fire extinguishers. The facility had a complete first aid kit and manual. The facility has an operable signal system that transmits audio signals. Fire safety installations such as extinguishers, sprinklers, and alarms are monitored by a third party authorized fire inspection company and LPA observed proof of inspection completed in November 2023. Fire extinguishers were observed to be charged and last inspected on 02/29/2024.

Storage and Supplies: Activities were observed to be available in the main lodge and appear to be a sufficient amount for the requested census. A locked medication room has resident medication, some supplies, and resident medical files. The main office is available for other facility files and staff and resident records. Linens, and equipment are all in good repair and sufficient for approved census.

Food Service and Laundry: Utensils and dishware are sufficient for the requested capacity. The refrigerator and
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Fannell
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2024
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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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 ASSISTED LIVING FACILITY
FACILITY NUMBER: 365530184
VISIT DATE: 03/13/2024
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stove are in working order. There is a secured storage for sharps, and cleaning supplies and toxins were locked in a closet.

Bedrooms and Bathrooms: Resident bedrooms were adequately furnished appropriate closet space, appropriate linens and hygiene provisions, adequate lighting, and an operational smoke alarm and signal system. Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels and paper supplies. Water temperature measured from the main lodge and five (5) bathrooms from 5 resident buildings are between 108-120 degrees Fahrenheit.

Component III was discussed with Licensee. The pre-licensing inspection is complete and this facility has no deficiencies. Licensee has satisfied all requirements in accordance with Title 22, California Code of Regulations. An exit interview was conducted where this report was discussed with and a copy was provided Licensee at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Fannell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC809 (FAS) - (06/04)
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