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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604301
Report Date: 05/28/2024
Date Signed: 05/28/2024 03:36:03 PM


Document Has Been Signed on 05/28/2024 03:36 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 2FACILITY NUMBER:
374604301
ADMINISTRATOR:SIMSUANGCO, CHONAFACILITY TYPE:
740
ADDRESS:2013 FLYING HILLS COURTTELEPHONE:
(619) 258-0663
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY:6CENSUS: 6DATE:
05/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Chona Simsuangco, DirectorTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced Required 1 year Annual Visit. LPA was allowed entry by Chona Simsuangco, Director. LPA identified herself and disclosed the purpose of the visit with the Director.

Physical Environment:  The facility was found to be clean, maintained, and free from any safety hazards.Adequate lighting and ventilation were observed in all areas of the facility. All necessary safety equipment, such as fire extinguishers and emergency exits, were present and in good working condition. The facility's outdoor spaces were properly maintained and accessible to residents.

Staffing and Training:  The facility had a sufficient number of qualified staff members to meet the needs of the residents.  The staff member was observed to be professional, courteous, and knowledgeable in their respective roles.  All staff members had completed the required training and certifications per the licensing regulations.  Staffing schedules were posted and adhered to, ensuring adequate coverage at all times.

Resident Care and Services:  Residents' care plans were reviewed and found to be comprehensive and up-to-date.  Medication administration was observed to be in accordance with the facility's policies and procedures. Residents' nutritional needs were met, and the meals provided were nutritious and well-balanced. Recreational activities and social engagement opportunities were available to residents regularly.
Continued on 809C
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita HallTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2024
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 2
FACILITY NUMBER: 374604301
VISIT DATE: 05/28/2024
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Health and Safety:  Regular health assessments and monitoring of residents' well-being were conducted by qualified healthcare professionals.  Infection control measures were in place and followed by staff members. The facility had established protocols for emergencies and evacuation plans were readily available.

Overall, the facility was found to comply with the licensing regulations.  An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058) was provided to Chona Simsuangco, Director. Her signature on this form confirms receipt of the documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita HallTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC809 (FAS) - (06/04)
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