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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700739
Report Date: 06/26/2025
Date Signed: 06/26/2025 02:36:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
06/19/2025 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20250619113826
FACILITY NAME:PINES, THEFACILITY NUMBER:
312700739
ADMINISTRATOR:HENRY COLEFACILITY TYPE:
740
ADDRESS:500 W RANCHVIEW DRIVETELEPHONE:
(916) 672-5019
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:142CENSUS: 120DATE:
06/26/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Henry ColeTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Unlawful eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cassie Yang and Associate Governmental Program Analyst (AGPA) Dana Garcia arrived unannounced at the facility to investigate the allegation of the complaint. LPA and AGPA met with Executive Director and explained the purpose of the visit.

The course of the investigation, LPA conducted extensive interviews and file review of R1's records. For the allegation cited above, Unlawful eviction, based on the information provided, it is substantiated.

Please continue on LIC 9099-C.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025
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 59-AS-20250619113826
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PINES, THE
FACILITY NUMBER: 312700739
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/03/2025
Section Cited
CCR
87224(d)(1)(D)
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87224 Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts...(1)...shall include the following information: (D) The following exact statement as specified in Health and Safety Code Section 1569.683(a)(4)...

This requirement is not met as evidenced:
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Licensee is to revise R1's eviction letter and provide a copy to Licensing and R1.

Additionally, Licensee is to submit to Licensing a statement of understanding all resident's personal rights.
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Based on file review, Licensee did not comply to the section cited above as LPA and AGPA observed R1's eviction letter to be incompleted with the required criterias which poses a potential risk for residents in care.
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POC is due July 3, 2025.

Failure to provide POC by due date may result to a civil penalty.
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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.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250619113826
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PINES, THE
FACILITY NUMBER: 312700739
VISIT DATE: 06/26/2025
NARRATIVE
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LIC 9099-C

Allegation: Unlawful eviction

Based on file review of R1's eviction letter, it revealed letter was written on June 13, 2025; however, licensee failed to provide effective date of eviction, specific facts with time and/or date, resources available to assist with alternative housing, Community Care Licensing and Long Term Care Ombudsman information, and exact statement as specified in Health and Safety Code Section 1569.683(a)(4). Based on interview conducted with R1, it revealed R1 did not want to relocate to a new facility. R1 stated R1 wished to reside at a bigger community, not at a six bed board and care. Based on information provided by R1's current caregiver, they were informed that R1 is no longer "eligible" to reside at the facility and "needs full care services by a small facility".

The Department finds the allegation to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

LPA provided a copy of all personal rights and CCR 87224 Eviction Procedure to facility. Additionally, LPA obtained a copy of R1's admission agreement, LIC 602, eviction letter and progress notes.

Deficiencies cited on the attached LIC 9099-D.

An exit interview was conducted, copy of the report and appeal rights was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3