Pine Manor Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct an annual inspection. LPA met with administrator Gina hernandez to explain the purpose of the visit. Pine manor care home is a 6 bed facility currently 4 bedrooms 3 baths. fire extinguisher is dated 7/27/26, first aid kit has all required items, smoke/co alarms are functional. Physical inspection was conducted, the facility has 4 beds set up for clients, a shortage of 2. LPA asked to either change the license or add more beds. Administrator gave the statement that they are currently discussing converting a current staff room to a client room, the LPA gave guidance that the facility should include VMRC and the fire department into thier discussion and return a plan by eod 8/31/26 to the LPA via email (noel.wolfpetersen@dss.ca.gov) about how they will come into compliance regarding the physical requirements. LPA reviewed the staff files for staff trainings(current and annual), health screenings, backgound clearance, and first aid/cpr training. 1 client has restricted condiition(PEG tube) LPA asked for annual staff training to increase by 4 hours files for topics related to PEG care. otherwise files are present and up to date. LPA reviewed client files for the most recent 602, health creenings, ipps, and signed admission agreements. LPA asked for updated needs and services plans as frequently as necessary for the clients after changes to their care, (1 client had a new diagnosis after a fall). otherwise files are present and up to date. Administrator files were reviewed for required posters, evacuation policy, infection control policy, hiv/blood borne pathogen training, facility license, and administrator certificate. LPA asked for a copy of the HIV/blood borne pathogen certificate to be emailed to the LPA by eod 8/31/26. otherwise files are present and up to date. P+i and balance sheets are in accord for 2 clients at random. Mars and medications are in accord for 2 clients at random. a copy of the report was read and given to the administrator. LPA requested change of administrator docs to be sent to the LPA. no ciations issued as part of this visit. exit interview was conduct.the state’s words, verbatim · CDSS document, Aug 24, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a one year/required annual Inspection. LPA was met by Administrator Gina Hernandez and explained the reason for the visit. Census: 4 LPA Lund & Administrator Gina Hernandez toured/inspected the physical plant inside and outside to ensure all passageways, and other areas of potential hazard are free of obstruction. LPA observed the kitchen and dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. The temperature inside the building is measured at 75.0 *F which is within the required range of 68-85*F. The hot water temperature was measured at 110 within the required temperature of 105-120. LPA observed 2-day perishable and 7- day non-perishables during this visit. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and antiseptic solutions. LPA observed one fire extinguisher (4/14/2025), smoke and carbon monoxide detectors and pull alarm system. Facility also has central heating and air. LPA Lund reviewed 2 resident files, and 2 staff files were reviewed during this visit. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies. Exit interview held, copy of report left.the state’s words, verbatim · CDSS document, Aug 13, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a Required Annual Inspection. LPA was met by Administrator Sajida Khan and explained the reason for the visit. Census: 4 LPA Lund & Administrator Sajida Khan toured/inspected the physical plant inside and outside to ensure all passageways, and other areas of potential hazard are free of obstruction. LPA observed the kitchen and dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. The temperature inside the building measured at 74.0 *F which is within the required range of 68-85*F. The hot water temperature was measured higher than normal and the maintenance was working on their system to maintain the required temperature of 105-120. LPA observed 2-day perishable and 7- day non-perishables during this visit. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution. LPA observed the fire extinguisher(s) (3/4/2024), smoke and carbon monoxide detectors and pull alarm system. Facility also has central heating and air. LPA Lund reviewed 2 resident files and 2 staff files were reviewed during this visit. No violations were observed during this visit. Exit interview held, copy of report given.the state’s words, verbatim · CDSS document, Jul 29, 2024

Allegation investigated: Facility staff with holding resident PN&I based on behavior.

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation. LPA Lund met with Care Staff Evangeline Majidi and explained the reason for the visit. Facility staff with holding resident PN&I based on behavior- Based on records reviewed, interviews with clients, reporting party, witnesses and staff. LPA Lund reviewed PN&I records for clients in care from 9/1/2023 through 1/29/2024 and found no discrepancies for PN&I. LPA Lund interviewed clients in care who stated that facility staff have never withheld any PN&I from them. Staff interviewed have never seen clients not being able to access their PN&I. Witnesses interviewed stated that Client (C1) brings money (PN&I) for activities while C1 is in day program. Unsubstantiated Based on records review, interviews with clients, reporting party, witnesses and staff the information provided, it was unclear if facility staff with holding resident PN&I based on behavior therefore the allegation was deemed UNSUBSTANTIATED. The Department (CCLD) has found the allegations. Unsubstantiated. A finding that the complaint allegation(s) are UNSUBSTANTIATED means that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. Exit interview was conducted with Administrator Karen Fomby and report left.the state’s words, verbatim · CDSS document, May 6, 2024 · control 27-AS-20240123160938