365530184-4-22-2026-56-AS-NBRN-DTJPTX-20260427113639

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 365530184
Report Date: 04/22/2026
Date Signed: 04/22/2026 01:52:02 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
03/23/2026 and conducted by Evaluator Renese Howell-Small

COMPLAINT CONTROL NUMBER: 56-AS-20260323142957

FACILITY NAME:	PACIFIC PINES ASSISTED LIVING FACILITY		FACILITY NUMBER:	365530184
ADMINISTRATOR:	ZAMORA, JOEL		FACILITY TYPE:	740
ADDRESS:	5850 N MANZANITA AVE		TELEPHONE:	(909) 794-2225
CITY:	ANGELUS OAKS	STATE: CA	ZIP CODE:	92305
CAPACITY:	15	CENSUS: 13	DATE:	04/22/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Doug Hicks		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility did not provide water
Facility did not provide operable call lights
Staff are not CPR certified
Staff verbally abuse residents in care

INVESTIGATION FINDINGS:

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On 04/22/2026 at 9:30AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to investigate and deliver findings for the above allegations. LPA discussed the purpose of the visit with Administrator, Doug Hicks. The investigation consisted of interviews, observation and record review.

In regards to the allegation of facility did not provide water:
LPA interviewed four (4) staff and five (5) residents. LPA observed cups of water available in resident rooms. LPA observed a water cooler in the main dining area with additional gallons of water in the pantry. Staff denied the allegation and stated that water is always available. Residents stated that staff provide water. Based on interviews and observation, this allegation is UNSUBSTANTIATED.

In regards to the allegation of facility did not provide operable call lights:
LPA interviewed five (5) residents which stated that the call lights/buttons work. LPA observed call buttons

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20260323142957

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: 04/22/2026

NARRATIVE

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in resident rooms. LPA randomly tested call buttons and observed the signal alert staff in main dining
room area. Staff denied the allegation. LPA observed call buttons within reach for Resident 3 (R3) and Resident 4 (R4). Based upon interviews and observation, this allegation is UNSUBSTANTIATED.

In regards to the allegation that staff are not CPR certified:
LPA reviewed all current staff records which revealed valid CPR/First Aid certification and completed health screenings with tuberculosis (Tb) test result for each staff. Based on observation, this allegation is UNSUBSTANTIATED.

In regards to the allegation that staff verbally abuse residents in care:
Four (4) out of five (5) residents interviewed stated that staff are nice and treat residents well. Staff denied the allegation and stated that the residents are like family. Staff 3 (S3) stated that most of the residents are asleep during their shift. Based on interview, 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(s) occurred.

An exit interview was conducted where this report LIC9099, LIC9099C was discussed and a copy was provided to the Administrator, Doug Hicks.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

LIC9099 (FAS) - (06/04)

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