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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530184
Report Date: 10/03/2024
Date Signed: 10/03/2024 05:10:52 PM

Document Has Been Signed on 10/03/2024 05:10 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/
DIRECTOR:		ZAMORA, JOELFACILITY TYPE:
740
ADDRESS:5850 N MANZANITA AVETELEPHONE:
(909) 557-5477
CITY:ANGELUS OAKSSTATE: CAZIP CODE:
92305
CAPACITY: 15CENSUS: 14DATE:
10/03/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:House Manager, Douglas HicksTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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On 10/03/2024 at 1:30PM, Licensing Program Analysts (LPAs) Renese Howell-Small and Melody Brown conducted an unannounced visit at this location to commence a health and safety check. LPAs Howell-Small and Brown identified themselves and discussed the purpose of the visit with House Manager, Douglas Hicks due to complaint # 56-AS-20240925153435.

Fourteen (14) residents in care were present during visit. LPAs observed imminent health and/or safety concerns observed at the time of visit as LPAs conducted a medication audit for three (3) residents and noted that multiple medications were not given per their doctor’s order. Deficiency will be issued. LPAs observed health and/or safety hazards at this location as no sufficient staff coverage were observed to provide appropriate care and supervision to residents in care. During the visit, LPAs observed that only one (1) staff working from 6:00 AM to 2:00 PM and there are fourteen (14) residents of which three (3) residents are on hospice and three (3) residents have dementia. Deficiency will be issued. Furthermore, LPAs observed no emergency supplies available. Deficiency will be issued. Also, LPAs inspected the outside perimeter at this location and observed no health and/or safety hazards. LPAs inspected the food supplies at this location and observed an adequate supply of perishable and non-perishable food. The needs of the residents in care appear not being met during this inspection.

An exit interview was conducted where this report, LIC809, LIC809D and Appeal Rights were discussed and provided to House Manager, Douglas Hicks.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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Document Has Been Signed on 10/03/2024 05:10 PM - It Cannot Be Edited


Created By: Renese Howell-Small On 10/03/2024 at 04:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFIC PINES ASSISTED LIVING FACILITY
FACILITY NUMBER: 365530184

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... (4) The licensee shall assist residents with self-administered medications...
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Licensee has agreed to conduct Medication Training on CCR 87465(a)(4) to all staffs dispensing medications to residents and submit proof to LPA Howell-Small on Plan of Correction (POC) due date
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This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by not ensuring that staff are providing the required medication assistance to Resident #1 (R1), Resident #2 (R2) and Resident #3 (R3) as prescribed by their physician which poses an immediate health, safety, or personal rights risk to persons in care.

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Type A
10/04/2024
Section Cited
CCR87411(a)

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87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…This requirement is not met evidenced by:

Based on observation, interview and records review, the Licensee did not comply with the section cited above by not ensuring that there are sufficient

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Licensee stated to schedule additional staff to work at this location and submit proof of updated staff schedule to LPA Howell-Small on Plan of Correction (POC) due date.
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 number of staff working at this location as evidenced of LPAs observed during the visit at this location that only one (1) staff working the morning shift from 06:00 AM to 02:00 PM which poses an immediate health, safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/03/2024 05:10 PM - It Cannot Be Edited


Created By: Renese Howell-Small On 10/03/2024 at 04:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFIC PINES ASSISTED LIVING FACILITY
FACILITY NUMBER: 365530184

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2024
Section Cited
HSC
1569.695(a)(2)

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HSC 1569.695 Emergency Plans (a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to... This requirement is not met as evidenced by:
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Licensee stated to obtain and prepare the required emergency supplies/kits and emergency food and submit proof to LPA Howell-Small on Plan of Correction (POC) due date.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that this location has the required emergency supplies/kits and emergency food which poses a potential health, safety, or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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