198602965-8-26-2025-28-AS-MCOA-DKWP4G-20250826105906

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602965
Report Date: 08/26/2025
Date Signed: 08/26/2025 10:59:15 AM

Document Has Been Signed on 08/26/2025 10:59 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 HOME		FACILITY NUMBER:	198602965
ADMINISTRATOR/ DIRECTOR:	BUMANLAG, MYLENE		FACILITY TYPE:	735
ADDRESS:	12210 LOUIS AVE		TELEPHONE:	(562) 368-1479
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90605
CAPACITY: 6		CENSUS: 6	DATE:	08/26/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Evangeline Hughes, Caregiver		TIME VISIT/ INSPECTION COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual visit today. LPA met with Angeline Hughes, Caregiver and the reason for the visit was explained. Licensee, ----- arrived thereafter and continued to assist with the visit. The facility is licensed to serve 6 developmentally disabled adults ages 18 to 59 years old of which 2 may be non-ambulatory. The facility is operating within the scope of its license. Clients receive services through the Eastern Los Angeles Regional Center. The facility is in a residential area of Whittier, CA. During the visit, LPA toured the facility's indoor and outdoor environment, reviewed 6 client and 3 staff files and conducted medication review. The facility is a single-story house which consists of: living room, (2) dining areas, kitchen, (2) full bathrooms, (5) client bedrooms, (1) staff room, laundry room, front yard and backyard, patio area and detached garage. During today’s visit, LPA observed the following: Facility was observed clean, inside and out. All walkways, passages and exits are clear and free of debris and obstructions. Living room and dining areas have sufficient seating and furniture is in good repair. Kitchen was observed to be clean and sanitary for the storage and preparation of food. Kitchen appliances are clean and were operating at the time of visit. Cleaning supplies and toxins were observed locked in a cabinet under kitchen sink and inaccessible to clients. Knives/sharps were also properly locked in a kitchen drawer. ***Continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 08/26/2025

NARRATIVE

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Sufficient supply of (2) day perishable and (7) day non-perishable food was observed. Food is labeled and kept within expiration limits. Overflow refrigerator and freezer are kept in the garage and both contained additional food which was also observed to be properly labeled. Fresh fruit observed throughout the kitchen counter tops and caddy.
Client bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen and mattress pads.
Two (2) full bathrooms were inspected and were observed clean. The water temperature was tested in both bathrooms and measured 109.5 degrees F in bathroom 1 and 110.7 degrees F in bathroom 2 which is within the required 105 - 120 degrees F.
Laundry room is clean and appliances were observed to be working and in good repair. Detergents are kept locked in kitchen.
Interconnected smoke detectors were observed throughout the facility and were tested and observed to be working properly. The home is also equipped with (2) carbon monoxide detectors which were also tested and working properly. There is one fire extinguisher located in the kitchen which was observed to be charged and last serviced on 3/19/25. Drills are conduced quarterly. Last fire/safety drill was conducted on 8/9/25. First Aid kit was reviewed and observed to be properly stocked and to have all required tools and provider manual.

Outdoor environment:

The front and backyard are well maintained and there are no pools or large bodies of water. Backyard patio furniture was observed and is in good repair. A shaded area is available and garden is kept trimmed.

Staff/Client File and Medication Review:

Four (4) staff files were reviewed and staff have the required criminal background clearance. Six (6) client files were also reviewed and have the required documentation in place.
Client medication is centrally stored and kept locked in a cabinet. Three (3) client medication was reviewed and was observed to be administered according to physician’s orders and documented appropriately.

No deficiencies noted under Title 22 Regulations. during today's visit. Exit interview conducted with Jennifer KIm, Licensee and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025

LIC809 (FAS) - (06/04)

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