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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425568
Report Date: 12/14/2020
Date Signed: 12/14/2020 12:49:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PACIFIC PINESFACILITY NUMBER:
366425568
ADMINISTRATOR:NANCY THRANEFACILITY TYPE:
740
ADDRESS:1438 PACIFIC ST.TELEPHONE:
(909) 798-7077
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY:14CENSUS: 10DATE:
12/14/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Nancy ThraneTIME COMPLETED:
12:00 PM
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Due to the Department’s implementation, and in following current public health guidance, this report will be delivered via telephone. Licensing Program Analyst (LPA) Naisha Kendrix contacted the facility to follow up on a Confirmation of Removal Notification (COR). LPA spoke with the Administrator, Nancy Thrane, and discussed the reason for the call.

The Criminal Record Exemption needed notification letter dated 12/03/2020 was generated to notify the licensee that Erika Moore must not work or be present in the facility licensed by the Department unless a Criminal Record Exemption is granted. LPA discussed the confirmation of removal notice with Administrator Thrane. LPA was informed that Erika Moore was removed from the facility's training schedule once the notification was received and has not returned to the facility. The administrator understands that employee, Erika Moore cannot work, reside or be present in a facility licensed by the Department unless a Criminal Record Exemption is granted.

During this call, LPA requested that Administrator Thrane fill out the Confirmation of Removal Form to confirm that the mentioned staff person does not work, reside nor are present in any licensed facility. LPA was informed by Administrator, Thrane, that the COR was signed and returned via email to the office staff, Erin Bunnell, in the Regional Office.

Based on evidence obtained during today’s call, LPA has verified the individual is not present, employed, or residing at the facility. LPA advised the administrator to ensure this individual is disassociated from the facility roster.

An exit interview was conducted and a copy of this report was provided to Administrator, Thrane. The Administrator will review, sign, and return this report and the Confirmation of Removal forms within 24 hours of receipt.

Verification of removal is complete.
SUPERVISOR'S NAME: Edna MusokeTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Naisha KendrixTELEPHONE: (951) 204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2020
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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