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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602965
Report Date: 09/16/2022
Date Signed: 09/19/2022 03:38:39 PM

Document Has Been Signed on 09/19/2022 03:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PINE TREE FAMILY HOMEFACILITY NUMBER:
198602965
ADMINISTRATOR:BUMANLAG, MYLENEFACILITY TYPE:
735
ADDRESS:12210 LOUIS AVETELEPHONE:
(562) 368-1479
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY: 6CENSUS: 6DATE:
09/16/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rosita Ladera TIME COMPLETED:
12:45 PM
NARRATIVE
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LPA Angelica Rea conducted an unannounced visit for the purpose of conducting the Required annual inspection. On today's visit LPA met with Caregiver, Rosita Ladera who assisted with the visit.

LPA Rea discussed infection control practices with Administrator, toured the facility inside and out, reviewed food supply, reviewed staff files, and reviewed resident medications.

Bedrooms have the required furniture including bedframes, dressers, lamps and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The front and backyard are well maintained. The resident bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. The hot water temperature measured at 127.2 degrees F in bathroom #1, 124.2 degrees F in bathroom #2, and 126.2 degrees F in kitchen. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors located throughout the facility, tested and operational. There is a carbon monoxide detector, tested and operational. LPA observed a sufficient supply of PPE in the garage.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to Ms. Ladera.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/19/2022 03:38 PM - It Cannot Be Edited


Created By: Angelica Rea On 09/16/2022 at 11:57 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PINE TREE FAMILY HOME
FACILITY NUMBER: 198602965

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)


This requirement is not met as evidenced by: LPA oberved that water temperature measured 127.2 degrees F in bathroom #1, 124.2 degrees in F in bathroom #2, and 126.2 degrees F in kitchen.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care. Hot water measured over 120 degrees F in 2 bathroom sinks and in kitchen sink, which is beyond the required 105 - 120 degrees.
POC Due Date: 09/23/2022
Plan of Correction
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Facility will submit a water temperature log to prove that water temperature has been lowered and meets the requirement.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022


LIC809 (FAS) - (06/04)
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