<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426701
Report Date: 03/29/2021
Date Signed: 03/29/2021 12:11:54 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/24/2021 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210324144558
FACILITY NAME:PACIFIC PINESFACILITY NUMBER:
366426701
ADMINISTRATOR:NANCY THRANEFACILITY TYPE:
740
ADDRESS:5850 MANZANITA AVE.TELEPHONE:
(909) 801-1133
CITY:ANGELUS OAKSSTATE: CAZIP CODE:
92305
CAPACITY:15CENSUS: 14DATE:
03/29/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ramon Accereto - Executive DirectorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
RSO is allegedly associated or present at this address/facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Crystal Colvin conducted an unannounced visit to deliver the findigs of the complaint with the above allegation. LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Executive Director Ramon Accereto.

Regarding allegation "RSO is allegedly associated or present at this address/facility": The Department conducted interviews and reviewed documents from the facility for staff member (S1), which revelead that S1 had been employed at working at the facility since July 2020, an was currently still working at the facility as a cook, as of the Department's visit date on March 24, 2021. Interviews revealed that S1 was not fingerprinted and no background clearance check was run since the date of employement. Evidence obtained during this investgiation shows that S1 is a registered sex offender (RSO) with a criminal conviction and is ineligable to work at a Community Care Facility. Therefore, based on interviews and observations, the allegation of "RSO is RSO is allegedly associated or present at this address/facility" is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
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 3
Control Number 18-AS-20210324144558
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 PINES
FACILITY NUMBER: 366426701
VISIT DATE: 03/29/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited civil penalties of $100 per day that S1 worked for a maximum of 5 days (total $500), and deficiency noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy of all reports, forms, and appeal rights were provided to Executive Director Ramon Accereto during the exit interview
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20210324144558
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 PINES
FACILITY NUMBER: 366426701
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2021
Section Cited
CCR
87355(e)(1)
1
2
3
4
5
6
7
Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department...
1
2
3
4
5
6
7
S1 has been removed from the facility since 3/24/21. No further Plan of Correction needed.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:
Licensee did not comply with this regulation as S1 was working at the facility from July 2020 to March 2021 without a criminal background clearance or fingerprint clearance. This posed an immediate health and safety risk to all residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3