Pacific Hills Care Home

Allegation investigated: Facility accepted a non-ambulatory resident without proper fire clearance

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 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.the state’s words, verbatim · CDSS document, Sep 18, 2026 · control 27-AS-20260915155349

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87202(a) · Plan of correction due date: Sep 25, 2026

(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, 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.the state’s words, verbatim · CDSS document, Sep 18, 2026

Plan of correction: 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.

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Required - 1 Year

On 04/21/2026 at 1:35 PM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived at the facility to conduct an unannounced annual inspection. LPA Hughes met with Christopher and explained the purpose of the visit. The facility designated administrator was informed that CCLD was present in the facility. The current census is 1 with 1 facility staff present. This facility is a single story building licensed to serve (4) non-ambulatory residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 115.3 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in the kitchen area and was last serviced on 11/17/2025. LPA observed the facility has a public telephone in the common area and the facility has the required posters posted. Facility thermostat was observed at 68 degrees Fahrenheit. LPA observed toxins located in the kitchen cabinet kept locked and inaccessible to residents. LPA observed sharp knives kept locked in the kitchen and inaccessible to residents. Continuation 809-C LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 1 out of 1 residents medications and the medication administration record (MAR) was complete. The first aid kit was checked and contained the required components. LPA requested resident and staff files for review. LPA reviewed 1 out of 1 resident files and they were complete. LPA reviewed 6 staff files, and it was complete. LPA reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared. The following documents will be email to LPA by 04/21/2026 (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (3) LIC 610 Current Emergency Disaster Plan (4) Proof of Current Liability Insurance (5) LIC 500 Current Personnel Report As a result of this annual visit, the facility is in compliance with Title 22 Regulations, and a copy of these LIC 809 reports were provided to the facility via email..the state’s words, verbatim · CDSS document, Apr 21, 2026

Type of visit: Case Management - Health Checks

This visit was a follow-up to the Pre-Licensing inspection conducted on July 25, 2025, intended to verify compliance and confirm that all previously identified items had been addressed. LPA Lee toured the facility with administrator Lit Tien and House Manager Christopher Sinon. The facility’s physical plant was observed to be clean, well furnished, and sanitary. Fresh fruits and vegetables were readily available to Residents. All mattresses were equipped with proper bedbug casings. The garage was inspected and found to be free of sharp or toxic items. The emergency kit was present and adequately stocked. No personal belongings were observed in the facility at the time of the visit. During today’s visit, the administrator Tien stated that he is no longer using a Ring doorbell and that it was removed. LPA Lee observed that a regular doorbell was installed instead. Facility records related to the items listed below were readily available for review and were found to be current. · Surety bond · Mattress encasements for bedbug prevention · Garage storage free of sharp or toxic items · Availability of sample staff and client records · Admission agreements CONTINUED LIC 809-C · Infection control plan · Plan of operation · Emergency kit · Properly sized and displayed required posters · Updated LIC 308 and LIC 500 forms · Removal of all personal belongings from the facility · Availability of fresh fruits and vegetables As a result, of this visit, no deficiencies were cited per Title 22 Regulations. An exit interview was conducted, and a copy of this report was given to the administrator Tien at the facility.the state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: Prelicensing

On 4/25/25, at 830, Licensing Program Analyst(LPA) Noel Wolf Petersen and Licensing Program Manager(LPM) Liza King, arrived announced to do a prelicensing inspection. They were met by administrator Lit Tien and staff Chris Sinon, and explained the purpose of the visit. The Physical Plant was inspected, including but not limited to the recreation areas, living room, storage, hallways, client bedrooms, client bathrooms, and kitchen. The facility was found to be in physical compliance with the required furnishings and cleanliness. No bodies of water were observed. The first aid kit was inspected and found to have the required items, the fire extinguishers was stored properly and checked on 11/21/24 and found in compliance. The bathrooms had the resident temperature at 117.3*F, between the required 105-120. The trash cans were clean and secured, the food storage had 2 days of perishables, and 7 days of non-perishable food as per regulation. Sharps and toxics were stored in locked containers, medication storage was ready and available. In a subsequent prelicensing inspection the LPA is recommending that the the following are available for inspection/review: surety bond, that have bedbug casing for the mattresses, storage in the garage is clear of sharps and toxics, that the sample staff and client records are available, that the admission agreement, infection control plan, and plan of operation are ready to review, that they have and emergency kit with items and sample documentation ready to go, posters should be of correct dimension, updated LIC 308 and 500, notification for audio visual surveillance on the front door, all personal belongs removed from the facility, and fresh fruit and vegetables available for clients. Continued on c page The facility is ready to be licensed, however prior to accepting any clients into care a reinspection must occur. The assigned anaylst is Pang Lee 916-508-9726. The facility is pending vendorization to provide services to elderly 4I individuals. During this time, the licensee agreed to the following: they will maintain their fees with licensing they will notify community care licensing before a client arrives they will maintain control of the property a mandatory reinspection will occur before accepting residents they will maintain contact information by phone and email. An exit interview was conducted and the report read and delivered to the staff. COMP III was not conducted on this date, the licensee is an already existing licensee with a home operating in the Regional Office and in compliance.the state’s words, verbatim · CDSS document, Apr 25, 2025

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 4 Census (if any clients in care): 0 COMP II Participants: TIEN, LIT - Licensee/Administrator Interview Method: Telephone interview On 04/01/2025, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Apr 1, 2025