<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198203050
Report Date: 08/10/2023
Date Signed: 08/10/2023 02:23:29 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
12/22/2022 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20221222123113
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: 4DATE:
08/10/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rafael Lopez - AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff will not allow resident to return to the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent visit to investigate the allegation listed above. Upon arrival LPA met with Administrator Rafael Lopez and explained the reason for the visit.
On 12/27/2022 at approximately 12:50pm, LPA initiated the initial complaint visit and conducted physical plant, interviewed staff and reviewed and obtained copies of pertinent documents relevant to the investigation. Today LPA conducted physical plant, interviewed Administrator and obtained additional pertinent documents relevant to the investigation.

It was reported that staff will not allow resident to return to the facility, as it was alleged that the Administrator was attempting to illegally evict Resident 1 (R1). Interviews conducted and records review revealed, that on 12/03/2022, R1 sustained a fall at a local event, R1 returned to the facility on 12/4/2022, then on 12/05/2022, R1 was admitted to a local hospital for a humeral Fracture, a bruise on the upper left side of the eyebrow, dislocated shoulder and possible fractures of left ribs.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
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-20221222123113
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: 08/10/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 9099

It was determined that surgery would be required. On 12/15/2022, during a pre-op appointment, it was notated by the Administrator that R1's health was deteriorating since the fall occurred, as it was noted that R1 required more frequent assistance to get out of bed and to the shower. Administrator requested that R1s case worker evaluate R1's health needs as R1 may require the services of a  Skilled Nursing Facility (SNF). On 12/20/2022,  surgery occurred. On 12/21/2022, review of hospital notes indicated, that a Hospital social worker discussed with R1 about being discharged to a SNF. R1 agreed with the social worker to be relocated to a SNF. On 12/22/2022, the social worker informed the Administrator that R1 will be discharged to a local SNF. R1 did not return to this facility. Based on information obtained during the course of the investigation, the department does not have sufficient evidence to confirm this allegation occurred. Therefore the allegation that staff will not allow resident to return to the facility is deemed Unsubstantiated at this time.

Exit interview conducted and copy of the report issued to Administrator.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2