Pacific Pines Assisted Living Facility

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

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 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.the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 56-AS-20260323142957

Type of visit: Required - 1 Year

On 03/27/2026 at 9:50AM, Licensing Program Analyst (LPA) Renese Howell-Small arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator, Doug Hicks and introduced self and stated the purpose of the visit. LPA was informed that there are currently eleven (11) residents in care. The facility has five cabins with two (2) rooms, one room is private and the other is shared. Each room has its own restroom. There is a kitchen/dining area, living room, office, laundry, and backyard area with (3) three sheds. LPA completed a walk through of facility, review of records and medication audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 114 degrees Fahrenheit. The facility is equipped with operational smoke detectors/ carbon monoxide alarms and fire extinguishers which were tested and serviced by a third party on 02/06/2026 and first aid kit with book. Postings: Posters such as; the personal rights, emergency disaster plan, CCLD complaint poster and ombudsman were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed to be locked and inaccessible to residents. There is no swimming pool, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for residents in care. Dishes, cups, and utensils were also stored properly. Yards/Outside: LPA observed two (2) shaded patio areas and several outdoor benches in the courtyard area. Record Review: LPA reviewed staff and administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. All of the files reviewed were complete. Two deficiencies were cited and four (4) Technical Violations were given during this visit. An exit interview was conducted where this report LIC809, LIC809C , LIC809D, LIC9102 and Appeal Rights were discussed and copies were provided to Administrator, Doug Hicks.the state’s words, verbatim · CDSS document, Mar 27, 2026

The state marks this report as 8 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 05/13/2025 at 9:15AM, Licensing Program Analyst (LPA) Renese Howell-Small arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator Doug Hicks and introduced self and stated the purpose of the visit. LPA was informed that there are currently fourteen (14) residents in care. The facility has five cabins with two (2) rooms, one room is private and the other is shared. Each room has its own restroom. There is a kitchen/dining area, living room, office, laundry, and backyard area with (3) three sheds. LPA completed a walk through of facility, review of records and medication audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 114 degrees Fahrenheit. The facility is equipped with operational smoke detectors/ carbon monoxide alarm which was tested during the visit, charged fire extinguishers and first aid kit. Postings: Posters such as; the personal rights, emergency disaster plan, CCLD complaint poster and ombudsman were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed to be locked and inaccessible to residents. There is no swimming pool, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for residents in care. Dishes, cups, and utensils were also stored properly. Yards/Outside: LPA observed two (2) shaded patio areas and several outdoor benches in the courtyard area. Record Review: LPA reviewed staff and administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. One (1) Technical Violation was given during this visit. An exit interview was conducted where this report LIC809, LIC809C and LIC9102 were discussed and copies were provided to Administrator, Doug Hicks.the state’s words, verbatim · CDSS document, May 13, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility is violating residents' personal rights Staff is providing care while under the influence of drugs

On 12/23/2024 at 9:05AM 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 House Manager, Doug Hicks. LPA also interviewed and met with Administrator, Joel Zamora. LPA conducted a brief tour of the facility. The investigation consisted of interviews and record review. In regards to the allegation of facility is violating residents' personal rights: LPA interviewed five (5) staff and ten (10) residents. LPA observed some residents in their rooms and in the main kitchen area interacting with each other and staff members. Residents were observed to be talkative, friendly and content. Residents interviewed confirm that they are treated well and get the help that they need. LPA observed four (4) staff providing care, confirmed staff cleaning schedule and observed residents eating breakfast and a staff preparing a hot lunch for residents in care. The allegation is UNSUBSTANTIATED. Unsubstantiated In regards to the allegation of staff is providing care while under the influence of drugs: LPA interviewed five (5) staff and ten (10) residents. Both staff and residents deny witnessing staff provide care while under the influence of drugs. LPA observed the four (4) staff working at the facility during the visit to be alert, attentive to residents and able to answer LPA's questions clearly and with confidence. The 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 and LIC9099C was discussed and a copy was given to House Manager, Doug Hicks.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 56-AS-20240925153435

Allegation investigated: Staff do not ensure that residents are utilizing the stairs in a safe manner. Staff do not ensure that the facility is secure and free from wildlife.

Second Complaint: Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to deliver findings on the allegations listed above. LPA Beena Singh met with Facility Manager Doug Hicks and explained the purpose of the visit. The investigation consisted of interviews and review of records. First allegation, Staff do not ensure that residents are utilizing the stairs in a safe manner. During interviews with residents, all six residents who were interviewed denied having safety issues in the facility. Residents were happy with safety measures facility takes to keep them safe. Stairs are used only for residents who can walk on their own, but staff supervises them. Staff reported that there is a ramp built at the facility which allows residents to use their wheelchairs or four-wheel walkers. During an evacuation facility staff helped supervise residents. Unsubstantiated Second allegation, Staff do not ensure that the facility is secure and free from wildlife. During interviews with residents, all six residents who were interviewed denied having any issues with wild animals. Residents deny any issues with wildlife sighting at the facility, Staff reported that bins are kept clean and with heavy padlock, so no wild animals have access to food waste bins. Based on the evidence found during the investigation, LPA Beena Singh found the allegations listed above to be Unsubstantiated. Unsubstantiated: A finding that the complaints are Unsubstantiated means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California.the state’s words, verbatim · CDSS document, Nov 20, 2024 · control 56-AS-20241112155216

Allegation investigated: Licensee did not ensure facility evacuation plan provides safe temporary accommodations for residents.

Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to deliver findings on the allegations listed above. LPA Beena Singh met with Facility Manager Doug Hicks and explained the purpose of the visit. The investigation consisted of interviews and review of records. First Complaint: Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Manager Doug Hicks and explained the purpose of the visit. The investigation consisted of interviews and review of records. First allegation: Licensee did not ensure facility evacuation plan provides safe temporary accommodations for residents. Staff reported that the facility has two designated evacuation sights in Calimesa. During a recent fire the facility was required to evacuate, and residents were relocated to a motel. No evacuation chair needed, according to the fire department pre-licensing report. According to six out of six residents the motel provides food and accommodation. Unsubstantiated Residents stated staff provide supervision at the motel and staff reporting providing supervision to the resident while staying at the hotel, Staff provided day and night supervision while staying at the evacuation site Calimesa motel. Based on the evidence found during the investigation, LPA Beena Singh found the allegations listed above to be Unsubstantiated. Unsubstantiated: A finding that the complaints are Unsubstantiated means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Facility Manager Doug Hicks.the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 56-AS-20241113114026

Type of visit: Collateral

On 10/03/2024 at 1:30PM, Licensing Program Analysts (LPAs) Renese Howell-Small and Melody Brown conducted an unannounced visit at this location to commence a health and safety check. LPAs Howell-Small and Brown identified themselves and discussed the purpose of the visit with House Manager, Douglas Hicks due to complaint # 56-AS-20240925153435. Fourteen (14) residents in care were present during visit. LPAs observed imminent health and/or safety concerns observed at the time of visit as LPAs conducted a medication audit for three (3) residents and noted that multiple medications were not given per their doctor’s order. Deficiency will be issued. LPAs observed health and/or safety hazards at this location as no sufficient staff coverage were observed to provide appropriate care and supervision to residents in care. During the visit, LPAs observed that only one (1) staff working from 6:00 AM to 2:00 PM and there are fourteen (14) residents of which three (3) residents are on hospice and three (3) residents have dementia. Deficiency will be issued. Furthermore, LPAs observed no emergency supplies available. Deficiency will be issued. Also, LPAs inspected the outside perimeter at this location and observed no health and/or safety hazards. LPAs inspected the food supplies at this location and observed an adequate supply of perishable and non-perishable food. The needs of the residents in care appear not being met during this inspection. An exit interview was conducted where this report, LIC809, LIC809D and Appeal Rights were discussed and provided to House Manager, Douglas Hicks.the state’s words, verbatim · CDSS document, Oct 3, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 4, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... (4) The licensee shall assist residents with self-administered medications... This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by not ensuring that staff are providing the required medication assistance to Resident #1 (R1), Resident #2 (R2) and Resident #3 (R3) as prescribed by their physician which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 3, 2024

Plan of correction: Licensee has agreed to conduct Medication Training on CCR 87465(a)(4) to all staffs dispensing medications to residents and submit proof to LPA Howell-Small on Plan of Correction (POC) due date

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(a) · Plan of correction due date: Oct 4, 2024

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…This requirement is not met evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by not ensuring that there are sufficient number of staff working at this location as evidenced of LPAs observed during the visit at this location that only one (1) staff working the morning shift from 06:00 AM to 02:00 PM which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 3, 2024

Plan of correction: Licensee stated to schedule additional staff to work at this location and submit proof of updated staff schedule to LPA Howell-Small on Plan of Correction (POC) due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(a)(2) · Plan of correction due date: Oct 7, 2024

HSC 1569.695 Emergency Plans (a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to... This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that this location has the required emergency supplies/kits and emergency food which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 3, 2024

Plan of correction: Licensee stated to obtain and prepare the required emergency supplies/kits and emergency food and submit proof to LPA Howell-Small on Plan of Correction (POC) due date.

Type of visit: Prelicensing

Licensing Program Analysts (LPA) Anna Bueno conducted an announced pre-licensing inspection of the facility. LPA met with Licensees Joel and Lailanie Zamora who were informed of the purpose of today's visit. There are currently no residents in care. Application: The application is for a Residential Care Facility for the Elderly. Fire clearance has been granted for fifteen (15) non ambulatory, with rooms having been approved for bedridden residents . Fire inspection was on conducted on December 13,2023 by the San Bernardino County Office of the Fire Marshal. Buildings and Grounds: The facility is composed of six (6) one-story buildings. Five (5) buildings have two resident bedrooms and bathrooms. One common use building (main lodge) houses the kitchen, dining area, and medication room. The main office is attached to a resident building and the supply closet and laundry room is attached to another resident building. LPA and Licensees toured the interior and exterior of the facility. This facility has no bodies of water. A shaded siting area is available for residents. LPA and Licensees observed that ramps and walkways are free of obstruction. The facility has a working telephone for residents use. LPA and Licensees observed charged fire extinguishers. The facility had a complete first aid kit and manual. The facility has an operable signal system that transmits audio signals. Fire safety installations such as extinguishers, sprinklers, and alarms are monitored by a third party authorized fire inspection company and LPA observed proof of inspection completed in November 2023. Fire extinguishers were observed to be charged and last inspected on 02/29/2024. Storage and Supplies: Activities were observed to be available in the main lodge and appear to be a sufficient amount for the requested census. A locked medication room has resident medication, some supplies, and resident medical files. The main office is available for other facility files and staff and resident records. Linens, and equipment are all in good repair and sufficient for approved census. Food Service and Laundry: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. There is a secured storage for sharps, and cleaning supplies and toxins were locked in a closet. Bedrooms and Bathrooms: Resident bedrooms were adequately furnished appropriate closet space, appropriate linens and hygiene provisions, adequate lighting, and an operational smoke alarm and signal system. Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels and paper supplies. Water temperature measured from the main lodge and five (5) bathrooms from 5 resident buildings are between 108-120 degrees Fahrenheit. Component III was discussed with Licensee. The pre-licensing inspection is complete and this facility has no deficiencies. Licensee has satisfied all requirements in accordance with Title 22, California Code of Regulations. An exit interview was conducted where this report was discussed with and a copy was provided Licensee at the conclusion of the inspection.the state’s words, verbatim · CDSS document, Mar 13, 2024

Type of visit: Office

Facility Type: Residential Care Facility for the Elderly Application Type: Change of ownership Capacity: 15 Census (if any clients in care): 14 COMP II Participants: Joel Zamora, Lailanie Zamora Interview Method: Telephone interview On December 26, 2023, 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 the understanding of the California Code Title 22 Regulations. 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. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Dec 26, 2023