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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530184
Report Date: 09/09/2026
Date Signed: 09/09/2026 02:24:40 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
07/14/2026 and conducted by Evaluator Renese Howell-Small
COMPLAINT CONTROL NUMBER: 56-AS-20260714154348
FACILITY NAME:PACIFIC PINES ASSISTED LIVING FACILITYFACILITY NUMBER:
365530184
ADMINISTRATOR:ZAMORA, JOELFACILITY TYPE:
740
ADDRESS:5850 N MANZANITA AVETELEPHONE:
(909) 794-2225
CITY:ANGELUS OAKSSTATE: CAZIP CODE:
92305
CAPACITY:15CENSUS: 13DATE:
09/09/2026
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Administrator, Doug HicksTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff do not ensure resident's incontinence needs are being met
Staff speak inappropriately to resident
Staff do not ensure resident's toileting needs are being met
Staff do not ensure resident's equipment is in good repair
Staff do not assist resident in obtaining medical care
Staff leave resident in bed for an extended period of time
Staff do not allow resident to communicate with advocate
INVESTIGATION FINDINGS:
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On 09/09/2026 at 10:25AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA discussed the purpose of the visit with the Administrator, Doug Hicks. The investigation consisted of interviews, record review and observation.

In regards to the allegation of staff do not ensure resident's incontinence needs are being met:
LPA interviewed staff and residents. Staff stated that residents are checked every two (2) hours and their assistance is documented. Residents stated that their incontinence needs are met. LPA did not observe any mal odors in resident rooms. LPA also observed incontinence documentation for specific residents. Based on interviews and observation, this allegation is UNSUBSTANTIATED.

n regards to the allegation of staff speak inappropriately to resident:
LPA interviewed staff and residents. Staff denied the allegation and stated that residents are treated as family.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

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

DATE: 09/09/2026
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 2
Control Number 56-AS-20260714154348
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/09/2026
NARRATIVE
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Residents denied the allegation and stated that staff treat them respectfully. Based on interview, this allegation is UNSUBSTANTIATED.

In regards to the allegation of staff do not ensure resident's toileting needs are being met:
LPA interviewed staff and residents. Staff denied the allegation and stated that residents are assisted at least every two (2) hours or more when needed. Residents stated that staff assist them with their toileting needs. Based on interviews, this allegation is UNSUBSTANTIATED.

In regards to the allegation of staff do not ensure resident's equipment is in good repair:
LPA interviewed staff and Resident 1 (R1). R1 denied the allegation and stated that staff were in the process of ordering a more suitable wheelchair. Staff stated that they were in contact with the family of R1 and the insurance company to order a wheelchair. Based on interview, this allegation is UNSUBSTANTIATED.

In regards to the allegation of staff do not assist resident in obtaining medical care:
LPA interviewed staff and Resident 1 (R1). Staff stated that they are in communication with the family of R1 and the physician. LPA observed that R1 was seen by a physician via telehealth on 04/20/2026 and 05/12/2026. R1 denied the allegation and stated that they have been seen by a physician. Based on interview and record review, this allegation is UNSUBSTANTIATED.

In regards to the allegation of staff leave resident in bed for an extended period of time:
LPA interviewed staff and Resident 1 (R1). LPA reviewed records which confirmed that R1 is bedbound and ambulates with a wheelchair. Staff stated that they assist R1 with transfers. R1 stated that staff assist with their mobility and leaves the facility several times a week for medical appointments. Based on record review and interviews, this allegation is UNSUBSTANTIATED.

In regards to the allegation of staff do not allow resident to communicate with advocate:
Based on record review, LPA observed that Resident 1 (R1) is part of the Assisted Living Waiver Program which assists with advocacy. LPA interviewed staff. Staff denied the allegation and stated that R1 has a mobile phone. R1 stated that they spoke with an advocate on several occasions. Based on interview and record review, this allegation is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted where this report LIC9099, LIC9099C was discussed and copies were provided to the Administrator.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

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

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