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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198203050
Report Date: 03/21/2022
Date Signed: 03/21/2022 02:41:13 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/16/2022 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20220316100228
FACILITY NAME:PIONEER HOMEFACILITY NUMBER:
198203050
ADMINISTRATOR:RAFAEL LOPEZFACILITY TYPE:
736
ADDRESS:7402 HASKELL AVE.TELEPHONE:
(818) 787-2403
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 5DATE:
03/21/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rafel Lopez - ManagerTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
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9
Staff did not serve residents their meals during quarantine
INVESTIGATION FINDINGS:
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2
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5
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Licensing Program Analyst (LPA) Brian Balisi, conductedn unannounced complaint visit to investigate the allegation listed above. Upon arrival LPA met with Rafael Lopez Veronica Perez and explained the reason for the visit.

At 10:00am, LPA conducted physical plant tour, interviewed (5) residents, interviewed staff, and reviewed and obtained copies of pertinent documents relevant to the investigation.

Regarding the allegation, that Staff did not serve residents their meals during quarantine, LPA interview with (5) residents revealed that most residents stated that facility staff provided residents with meals throughout the day during quarantine. Interviews with residents further revealed that most did not express any immediate or potential concerns of meals not being served as each resident stated that staff consistently offer meals throughout the day for breakfast, lunch, dinner and snacks in between.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 29-AS-20220316100228
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PIONEER HOME
FACILITY NUMBER: 198203050
VISIT DATE: 03/21/2022
NARRATIVE
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Continued from 9099

LPA records review of Resident 1 (R1)'s and Resident 2 (R2)'s daily nursing notes revealed that R1 and R2 were served meals throughout the day while in quarantine . Today between 11:30am - 12:30pm, LPA observed staff offer to make turkey sandwiches to residents in care. During physical plant, LPA observed a sufficient supply of perishable and non-perishable foods to serve the residents in care at this time. Based on information gathered during this visit, the department does not have enough information to support the above allegation. Therefore the allegation of Staff did not serve residents their meals during quarantine has been deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Report issued and sent via Email.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2