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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604301
Report Date: 05/19/2025
Date Signed: 05/19/2025 12:23:17 PM

Document Has Been Signed on 05/19/2025 12:23 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/
DIRECTOR:		SIMSUANGCO, CHONAFACILITY TYPE:
740
ADDRESS:2013 FLYING HILLS COURTTELEPHONE:
(619) 258-0663
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
05/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:09 AM
MET WITH:Chona Simsuangco, DirectorTIME VISIT/
INSPECTION COMPLETED:
12:30 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, was 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.
Denise PowellTELEPHONE: (619) -76-2317
Renita HallTELEPHONE: (619) 767-2301
DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/19/2025
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Resident Care and Services:  Residents' care plans were reviewed and found to be comprehensive and up-to-date.  Medication administration was observed to be following 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.

Health and Safety: Qualified healthcare professionals conducted regular health assessments and monitored residents' well-being. Staff members followed infection control measures. 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: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC809 (FAS) - (06/04)
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