374604301-6-1-2023-08-AS-RGAZ-CSE25K-20230601170542

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604301
Report Date: 06/01/2023
Date Signed: 06/01/2023 05:05:47 PM

Document Has Been Signed on 06/01/2023 05:05 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	PINE TREE HOME 2		FACILITY NUMBER:	374604301
ADMINISTRATOR:	SIMSUANGCO, CHONA		FACILITY TYPE:	740
ADDRESS:	2013 FLYING HILLS COURT		TELEPHONE:	(619) 258-0663
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92020
CAPACITY:	6	CENSUS: 6	DATE:	06/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Licensee/Administrator Chona Simsuangco		TIME COMPLETED:	05:15 PM

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Licensing Program Analyst (LPA) Riza Alvarez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Caregiver Mark Bayaban. Licensee Chona Simsuangco arrived shortly.

According to the facility’s license, the facility has a maximum capacity of six (6) non-ambulatory residents, of which one (1) may be bedridden. During today’s inspection, six (6) residents are living in the facility.

LPA, accompanied by Licensee, 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. Resident rooms contain required furnishings. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant: Kitchen sink was 119 F, and bathroom #1 sink was 117 F, bathroom #2 sink was 119 F. Room temperature was 71 F.

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. There were no sharp objects, toxic chemicals/poisons, 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: John Rante	TELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Riza Gloria Alvarez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PINE TREE HOME 2	FACILITY NUMBER: 374604301
	VISIT DATE: 06/01/2023

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[CONTINUED FROM LIC809]

No pools or bodies of water on the premises. Per Licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was serviced within the last 12 months. First aid kits (2) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and residents. LPA reviewed multiple staff and resident records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Licensee to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Riza Gloria Alvarez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

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