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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701561
Report Date: 09/18/2026
Date Signed: 09/18/2026 10:16:59 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/15/2026 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260915155349
FACILITY NAME:PACIFIC HILLS CARE HOME, LLCFACILITY NUMBER:
342701561
ADMINISTRATOR:TIEN, LIT AFACILITY TYPE:
740
ADDRESS:8676 PACIFIC HILLS WAYTELEPHONE:
(916) 687-1207
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:4CENSUS: 2DATE:
09/18/2026
UNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Lit TienTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility accepted a non-ambulatory resident without proper fire clearance
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mabel Cummings and Licensing Program Manager (LPM), Arielle Pascua inspected Pacific Hills Care Home LLC on 9/18/2026 at 8:50 AM responding to the allegation of fire clearance.
Current census was 2.
A review of two (2) resident files were conducted, 1 out 2 resident files reviewed had a non-ambulatory status on their physican report dated on 10/21/2025. In addition, a review of the facilities fire clearance was conducted, which revealed that the facility is licensed for four (4) ambulatory clients. An interview with the Facility Administrator (AD), Lit Tien was conducted. (AD) Lit stated that the facility has initiated the process of changing to a nonambulatory status, initiated a pre-inspection with the fire department, and has started on the changes necessary to accomodate nonambulatory residents. During the course of this visit, LPA Cummings and LPM Pascua conducted a tour of the facility. LPA and LPM observed new sliding doors in one of the unoccupied rooms and a new concrete path from the room's sliding doors to the emergency exit.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2026
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 27-AS-20260915155349
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PACIFIC HILLS CARE HOME, LLC
FACILITY NUMBER: 342701561
VISIT DATE: 09/18/2026
NARRATIVE
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Based on the information gathered, the facility accepted a non-ambulatory resident without proper fire clearance.

As a result, the allegations above are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

An immediate civil penalty is being issued today in violation of fire clearance 87202(a).

An exit interview was conducted with AD Tien and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 27-AS-20260915155349
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PACIFIC HILLS CARE HOME, LLC
FACILITY NUMBER: 342701561
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2026
Section Cited
CCR
87202(a)
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(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons,
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Administrator states they will provide a statement of correction including but not limited to submitting an updated LIC200 and facility sketch indicating non-ambulatory rooms by POC date.
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 the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
This requirement was not met as evidenced by LPA observation of one resident files stating nonambulatory status. Review of the facilities fire clearance revealed the facility is licensed for four (4) ambulatory clients, which poses a potential health, safety, or 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: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3