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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604301
Report Date: 03/13/2024
Date Signed: 03/13/2024 11:26:35 AM


Document Has Been Signed on 03/13/2024 11:26 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



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:
03/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Thelm David, House Manager
Chona Simsuangco, Licensee		TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Renita Hall conducted an unannounced case management visit to follow up on an incident reported to Community Care Licensing.  LPA met with Thelma David, House Manager, and discussed the purpose of the visit. Chona Simsuangco, Licensee.
 
Community Care Licensing received an incident report on March 11, 2024, in which it was reported that Resident #1 (R1) was pronounced deceased on March 8, 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.

 Chona Simsuangco, Licensee was provided a copy of this report, appeal rights (LIC9058 03/22), the LIC 811.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita HallTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
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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