Pine Tree Home 2

Type of visit: Required - 1 Year

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] [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.the state’s words, verbatim · CDSS document, Jun 1, 2023

Allegation investigated: Unlawful eviction

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 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.the state’s words, verbatim · CDSS document, Aug 25, 2022 · control 08-AS-20220822133602

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Sep 9, 2022

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). 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.the state’s words, verbatim · CDSS document, Aug 25, 2022

Plan of correction: Administrator Chona Simsuangco will complete a training with an outside source and provide proof of completion by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced Required 1 -Year Visit. LPA identified herself and was greeted and allowed entry to the facility by Chona Simsuangco, Administrator, and discussed the purpose of the visit. LPA conducted a tour of the facility with Chona Simsuangco, Administrator. In accordance with the Department’s Infection Control program, LPA provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan (LIC 808). LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; A sign-in policy enacted for all visitors; Face coverings worn by staff; Hand sanitizer/hand washing stations readily available; A designated visitation area; Emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE (Personal Protective Equipment). Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. No deficiencies were observed during today's visit. An exit interview was conducted with Chona Simsuangco, Administrator, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided to.the state’s words, verbatim · CDSS document, Apr 28, 2022