<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602620
Report Date: 05/21/2024
Date Signed: 05/30/2024 03:54:46 PM


Document Has Been Signed on 05/30/2024 03:54 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, LLCFACILITY NUMBER:
374602620
ADMINISTRATOR:SIMSUANGCO, LEONARDOFACILITY TYPE:
740
ADDRESS:4603 RAINIER AVENUETELEPHONE:
(619) 310-6966
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY:6CENSUS: DATE:
05/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:House manager Gloria Pascua TIME COMPLETED:
01:50 PM
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) Amy Rodgers conducted an unannounced case management visit to follow up on an incident reported to Community Care Licensing.  LPA met with House manager Gloria Pascua, and discussed the purpose of the visit.
 
Community Care Licensing received an incident report on April 26, 2024, in which it was reported that Resident #1 (R1) was pronounced deceased on April 26,2024 while in the hospital. R1 had a documented history of illness before they passed away.
  
During today's visit, LPA collected pertinent resident records and conducted a health and safety check of the residents in care. No deficiencies were cited during today’s visit.

 House manager Gloria Pascua, Licensee was provided a copy of this report, appeal rights (LIC9058 03/22), the LIC 811.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy RodgersTELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1