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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602965
Report Date: 09/21/2023
Date Signed: 09/21/2023 03:02:34 PM

Document Has Been Signed on 09/21/2023 03:02 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:
09/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mylene Bumanlag TIME COMPLETED:
03:20 PM
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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 Administrator, Mylene Bumanlag, and Licensee, Jennifer Kim.

LPA Rea toured the facility inside and out, reviewed food supply, reviewed staff files, resident 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 120 degrees F in 2 bathroom(s) and 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. Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical/mental capability. There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The foods are properly stored in the refrigerator.
Medications are centrally stored and in their original containers. LPA reviewed 6 residents' medications and they are being administered as prescribed by the physician. The facility has an Emergency Disaster Plan posted with contact numbers. Administrator's certificate expires on 10/30/2023.

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. Bumanlag.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2023
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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