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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604301
Report Date: 08/25/2022
Date Signed: 08/25/2022 12:27:03 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/22/2022 and conducted by Evaluator Vicky Williamson
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20220822133602
FACILITY NAME:PINE TREE HOME 2FACILITY NUMBER:
374604301
ADMINISTRATOR:SIMSUANGCO, CHONAFACILITY TYPE:
740
ADDRESS:2013 FLYING HILLS COURTTELEPHONE:
(619) 258-0663
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY:6CENSUS: 5DATE:
08/25/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Leonardo Simsuangco and Chona Simsuangco, Administrators TIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Unlawful eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced visit to initiate a complaint investigation regarding the above-mentioned allegation. LPA was greeted and granted entry into the facility by Leonardo Simsuangco, Administrator, to whom she discussed the purpose of the visit. LPA spoke with Chona Simsuangco, Administrator via phone, she arrived at the facility during the visit.

The Department’s investigation consisted of interviews with administrators, staff, outside sources and review of records to include resident records. It was alleged that C1 [Administrators were provided an LIC 811 Confidential Names List that identifies the client] was unlawfully evicted from the facility. C1 was admitted to the hospital on August 19, 2022 on a 5150 hold for their aggressive behavior and attempting to physically attack several elderly residents at the facility. Information received, reported that the facility denied C1’s return from the hospital to the facility. Administrator Chona Simsuangco acknowledged refusing the return of C1 to the facility; however, stated that she was not aware that the 3- day eviction notice filed on July 22, 2022, was no longer valid. Administrator stated that her major concern regarding C1’s return to the facility was the health and safety of the elderly residents in care.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 08-AS-20220822133602
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: PINE TREE HOME 2
FACILITY NUMBER: 374604301
VISIT DATE: 08/25/2022
NARRATIVE
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A review of records confirmed that a 3- day eviction notice was approved for C1 on July 22, 2022, due to C1’s behavior caused an immediate threat to the health and safety of them and others at the facility. C1 was not removed from the facility within the 3- day eviction time frame. Administrator stated that per outside source assisting with placement for C1, there was no placement available during that time. An outside source confirmed that the 3- day eviction notice was rescinded by Administrator Chona Simsuangco.

Interview conducted with an outside source revealed that the hospital staff was advised of the 3- day eviction notice for C1. Per outside source, Administrator Chona Simsuangco would not state when the 3- day eviction notice was dated. Per outside source, Administrator Chona Simsuangco continued to refuse the return of C1.

This Department has investigated the allegation of illegal eviction and has found that, based upon evidence gathered through investigative interviews and record review, the preponderance of the evidence standard has been met. Therefore, this allegation is deemed substantiated.



This deficiency is noted on the attached 9099-D and is cited in accordance with the California Code of Regulations, Title 22. A copy of this report along with the Licensee/Appeal Rights (LIC 9058) and LIC 811 were provided to Administrator Chona Simsuangco, and the signature on this form acknowledges receipt of these rights.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20220822133602
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PINE TREE HOME 2
FACILITY NUMBER: 374604301
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2022
Section Cited
CCR
87224(a)
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Eviction Procedures
The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5).
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Administrator Chona Simsuangco will complete a training with an outside source and provide proof of completion by POC date.
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This requirement was not met as evidence by:
Based on interviews and record review, the 3- day eviction notice approved on 7/22/22, was rescinded. Administrator Chona Simsuangco did not allow C1 to return to the facility.

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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.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3