Pine Tree Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to Administrator Chona Simsuango.. The facility's license shows a capacity of six (6) non-ambulatory residents, two (2) of which may be bedridden. The facility is additionally approved for two (2) hospice residents. LPA and Administrator Simsuango 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. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Kitchen area was clean and organized. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were locked and inaccessible to residents. Toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Administrator Simsuango to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 27, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Caregivers Gloria Pascua, Loida Sanga, and Rowena Estacio. Administrator Chona Simsuango arrived later in the visit. The facility's license shows a capacity of six (6) non-ambulatory residents, two (2) of which may be bedridden. The facility is additionally approved for two (2) hospice residents. During today’s inspection there were five (5) residents in care, but four (4) were out at program. LPA, Caregiver Pascua, and Administrator Simsuango 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. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Common resident bathroom sink read at 106F. 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 client activities. Kitchen area was clean and organized. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were locked and inaccessible to residents. [Continued on LIC 809-C] [Continued from LIC 809] No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Administrator Simsuango, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed two (2) staff and zero (0) clients, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Administrator Simsuango to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 20, 2025

Allegation investigated: Staff yells at resident Staff hits resident Staff interacts with residents in an inappropriate manner Staff threatens resident

Licensing Program Analyst (LPA) Amy Rodgers made an unannounced visit to open an investigation on the above-mentioned allegation. LPA identified herself and disclosed the purpose of her visit with Licensee/Administrator Chona Simsuangco On February 4th 2025 , Community Care Licensing (CCL) received a complaint alleging Staff 1 (S1) yells, hits, and acts inappropriately to clients and that S1 threatens Client #4(C4). During the investigation, LPA Rodgers made observations, conducted interviews, reviewed facility records, and interviewed outside sources. Regarding the allegation staff yells, hits and interacts with residents inappropriately. More specifically, it was reported staff #1(S1) yells at Client #1(C1) to move faster when walking; S1 flicks Client#3(C3) in the mouth; and S1 gives clients in the facility the middle finger when they are not looking. (continued on LIC 9099) Unsubstantiated Continued form 9099) Physician's report dated (8/20/2024) reveals C1 has history of hearing loss. C1 interview denies feeling uncomfortable when any staff asks them to hurry to the waiting transportation outside. Interviews with Client #2(C2) verify that C1 is hard of hearing and staff does talk loudly to C1. Interviews with staff confirm they must talk in a loud voice to C1 because they are hard of hearing. LPA observations reveal C3 does have mouth open at times and does drool. C3 is nonverbal, and LPA was unable to interview; however, interviews with C1 and C2 reveal they have never witnessed any staff flick C3 in the mouth. Staff and administrators deny ever witnessing any staff member flicking or inappropriately touching C3 in the mouth area. C1 and C2 deny ever witnessing staff giving anyone the middle finger. They further explain that the staff are nice and helpful. Staff and administrators also deny ever witnessing any staff member giving clients the middle finger. Outside source interviews reveal that no clients in the home have reported to them any accounts of staff not interacting appropriately with clients. Regarding the allegation that the staff threaten the resident. More specifically, S1 threatens to take Client #4(C4) cell phone and gifted earrings away if C4 moves out. The interview with the administrator indicates C4 does not own the cell phone; S1 owns the cell phone. Interviews with the administrator further explained that the earrings were a gift to C4. S1 denies making threats but does explain that the cell phone is theirs. Outside interviews reveal C4 does have a history of false accusations and attention-seeking behavior. Interviews with C1 and C2 reveal they have never witnessed threatening words to C4 by any staff member. Due to lack of corroborating evidence, the finding regarding the above allegations were established to be unsubstantiated. This finding means there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with Licensee/Administrator Simsuangco and a copy of this report along with Licensee Rights (LIC 9058 01/16) was provided to Licensee/Administrator Simsuangco. Signature on the for confirms receipt the reports were received.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 08-AS-20250204113009

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced case management visit to follow up on an incident reported to Community Care Licensing. LPA met with House manager Gloria Pascua, and discussed the purpose of the visit. Community Care Licensing received an incident report on April 26, 2024, in which it was reported that Resident #1 (R1) was pronounced deceased on April 26,2024 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. House manager Gloria Pascua, Licensee was provided a copy of this report, appeal rights (LIC9058 03/22), the LIC 811.the state’s words, verbatim · CDSS document, May 21, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection to ensure substantial compliance with Title 22 regulations. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with House Manager Gloria Pascua. Licensee Chona Simsuangco later joined the visit. According to the facility’s license, the facility has a maximum capacity of six (6), all of whom can be non-ambulatory. This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by licensee’s staff, 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. Client bedrooms contained the required furnishings. Toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was with regulation range. Hot water temperature at taps accessible to clients were all compliant. Refrigerator and Freezer temperature were complaint. 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 and in good repair. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] There is a not a pool on water feature on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with, Licensee Chona Simsuangco 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, Mar 12, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Domingo 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 Gloria Pascua. According to the facility’s license, the facility has a maximum capacity of six (6) clients, all of whom must be ambulatory. During today’s inspection, there were a total of six (6) clients in care, and per medical records, all were ambulatory. This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by licensee’s staff, 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. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. 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 client activities. The facility’s ambient internal temperature was 69 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 103 F, Bathroom #1 sink was 103 F, and Bathroom #2 sink was 103 F. Refrigerator temperature was 40 F and freezer temperature was 0 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, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809C] [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance and surety bond. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with House Manager Gloria Pascua, 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, Oct 17, 2023