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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602965
Report Date: 10/12/2024
Date Signed: 10/12/2024 11:49:20 AM

Document Has Been Signed on 10/12/2024 11:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PINE TREE FAMILY HOMEFACILITY NUMBER:
198602965
ADMINISTRATOR/
DIRECTOR:		BUMANLAG, MYLENEFACILITY TYPE:
735
ADDRESS:12210 LOUIS AVETELEPHONE:
(562) 368-1479
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY: 6CENSUS: 6DATE:
10/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:28 AM
MET WITH:Napoleon LaderaTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met DSP worker Napoleon Ladera at approximately 8:18 AM and explained reason for visit. Administrator Mylene Bumanlag arrived shortly.

Facility is licensed to serve (6) developmentally disabled adults, ages 18-59. Two can be non-ambulatory. The facility is in a residential area, and it is a one-story family home. A tour of the single-story facility included five (5) client bedrooms, one (1) staff room, living room, dining room, and kitchen, 2 shared bathrooms and detached garage.

LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in hallway closet. During tour LPA observed extra room not on floor plan and was told no permits were acquired. Smoke detectors/carbon monoxide detectors were observed in each room and throughout the facility and are properly operating. The facility has one (1) fully charged fire extinguishers which is kept in dining room. Cleaning supplies and toxic substances are inaccessible to clients in a locked storage in garage as well as within other locked cupboards in kitchen. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There is an extra freezer and refrigerator in garage with more food. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2024
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 10/12/2024 11:49 AM - It Cannot Be Edited


Created By: Christian Gutierrez On 10/12/2024 at 11:07 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: 10/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)(c)
80086 Alterations to Existing Building or New Facilities

(a) Prior to constuction or alterations, all licensees shall notify the licensing agency of the proposed change.
(c) Prior to construction or alterations, state or local law requires that all facilities secure a bulding permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observatio, the licensee did not comply with the section cited above ADU built for client as a bedroom with no permit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2024
Plan of Correction
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Administrator agrees to provide proof from city that they are trying to obtain permit and email to LPA.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PINE TREE FAMILY HOME
FACILITY NUMBER: 198602965
VISIT DATE: 10/12/2024
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Four (4) staff files were reviewed and included Criminal clearance record, CPR training, and health screening with TB. Six (6) client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP) report. Last fire/earthquake drill was conducted in July of 2024. Infectious control plan was reviewed. One (1) staff and (2) client was interviewed. Six (6) client medications were reviewed. Medications are centrally stored and locked MAR log is used.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2024
LIC809 (FAS) - (06/04)
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