374602620-3-12-2024-08-AS-AROS-D3B5Q9-20240312200906

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602620
Report Date: 03/12/2024
Date Signed: 03/12/2024 08:09:36 PM

Document Has Been Signed on 03/12/2024 08:09 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	PINE TREE HOME, LLC		FACILITY NUMBER:	374602620
ADMINISTRATOR:	SIMSUANGCO, LEONARDO		FACILITY TYPE:	740
ADDRESS:	4603 RAINIER AVENUE		TELEPHONE:	(619) 310-6966
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92120
CAPACITY:	6	CENSUS:	DATE:	03/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	House manager Gloria Pascua and Licinsee Chona Simsuangco		TIME COMPLETED:	04:30 PM

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Licensing Program Analysts (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection to ensure substantial compliance with Title 22 regulations. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with House Manager Gloria Pascua. Licensee Chona Simsuangco later joined the visit.

According to the facility’s license, the facility has a maximum capacity of six (6), all of whom can be non-ambulatory. This facility does not feature a secured perimeter or delayed egress doors.

LPA, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was with regulation range. Hot water temperature at taps accessible to clients were all compliant.

Refrigerator and Freezer temperature were complaint. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present and in good repair. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PINE TREE HOME, LLC	FACILITY NUMBER: 374602620
	VISIT DATE: 03/12/2024

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[CONTINUED FROM LIC 809]

There is a not a pool on water feature on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance.

No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with, Licensee Chona Simsuangco to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

LIC809 (FAS) - (06/04)

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