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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198203050
Report Date: 01/28/2025
Date Signed: 01/28/2025 10:53:32 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
01/15/2025 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20250115113144
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:
01/28/2025
UNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Rafael LopezTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Unlawful eviction
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced follow-up complaint investigation visit at the facility at 09:57 AM. LPA met with facility Administrator Rafael Lopez the reason for the visit was explained and entrance interview was conducted.

During the initial complaint visit on 01/22/2025 LPA conducted a physical plant tour to ensure there are no health and safety hazards, collected copies of pertinent documents, and conducted interviews with the Administrator, one (1) staff member, and two (2) residents. During today’s visit LPA conducted a brief physical plant tour, and interviewed the Administrator and one (1) resident between 09:57 AM and 10:40 AM.

Continued on LIC-9099C
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
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 6
Control Number 29-AS-20250115113144
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PIONEER HOME
FACILITY NUMBER: 198203050
VISIT DATE: 01/28/2025
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
The allegation of “Unlawful eviction” alleges that the facility issued an eviction notice to a resident that did not meet the requirements of title 22 regulations. LPA Byrne reviewed the eviction notice that was submitted to the regional office. LPA observed the eviction notice to be missing information required by CCR 87868.1(d) which states, “The licensee shall set forth in the notice the reasons for the eviction, with specific facts including the date, place, witnesses, and circumstances.” LPA did not observe the eviction notice to contain specific facts about the dates, places, witnesses, or circumstances for the eviction. Based on the information obtained during file review there is sufficient evidence to support the allegation of “Unlawful Eviction.” Therefore, the allegation is deemed Substantiated at this time.

The following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20250115113144
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PIONEER HOME
FACILITY NUMBER: 198203050
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/11/2025
Section Cited
CCR
87868.1(d)
1
2
3
4
5
6
7
87868.1 Resident Eviction Procedures
(d) The licensee shall set forth in the notice the reasons for the eviction, with specific facts including the date, place, witnesses, and circumstances.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will resubmit the eviction notice for Resident #1 with all required information to CCLD no later than POC due date.
8
9
10
11
12
13
14
Bassed on record review the licensee did not comply with the section cited above as the eviction notice for resident #1 did not contain specific facts including the date, place, witnesses, and circumstances pertaining to the eviction which poses a potential personal rights risk to clients in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
01/15/2025 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20250115113144

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:
01/28/2025
UNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Rafael LopezTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not providing adequate food service
Resident was hospitalized as a result of food poisoning
Staff are not following facility menu
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced follow-up complaint investigation visit at the facility at 09:57 AM. LPA met with facility Administrator Rafael Lopez the reason for the visit was explained and entrance interview was conducted.

During the initial complaint visit on 01/22/2025 LPA conducted a physical plant tour to ensure there are no health and safety hazards, collected copies of pertinent documents, and conducted interviews with the Administrator, one (1) staff member, and two (2) residents. During today’s visit LPA conducted a brief physical plant tour, and interviewed the Administrator, and one (1) resident between 09:57 AM and 10:40 AM.

Continued on LIC 9099C.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20250115113144
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PIONEER HOME
FACILITY NUMBER: 198203050
VISIT DATE: 01/28/2025
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
The allegation of “Resident was hospitalized as a result of food poisoning” alleges that a resident of the facility was hospitalized as a result of eating food that the facility prepared resulting in food poisoning. During the physical plant tour LPA observed the food of the facility to be stored properly and the facility’s refrigerator/freezer to be maintained at an appropriate temperature. An interview with S1 revealed that they follow appropriate hygiene and food safety procedures while preparing meals for the facility. An interview with Resident #2 (R2) did not reveal any concerns about the quality of food at the facility or the facility’s hygiene/food prep procedures. A review of the hospital paperwork for Resident #1 (R1) did not reveal sufficient evidence that the facility caused R1 to contract food poisoning from facility provided meals. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Resident was hospitalized as a result of food poisoning.” Therefore, the allegation is deemed Unsubstantiated at this time.

The allegation of “Staff are not providing adequate food service” alleges that facility staff do not serve an adequate amount of food to residents during mealtime. LPA interviewed Resident #2 (R2) who stated that the amount of food served with each meal was, “Plenty”. During staff # 1’s (S1) interview S1 they described the portions as “Good”. S1 stated that they sometimes cook meals for the residents and will give the residents additional food if they ask for it. During the physical plant tour LPA observed adequate food supplies stored at the facility. All food supplies observed were within their expiration dates and appeared to be of good quality. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff are not providing adequate food service”. Therefore, the allegation is deemed Unsubstantiated at this time.

Continued on LIC 9099C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20250115113144
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PIONEER HOME
FACILITY NUMBER: 198203050
VISIT DATE: 01/28/2025
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
The allegation of “Staff are not following facility menu” alleges that the facility staff do not follow the facility’s menu when preparing meals for the residents. An interview with R2 revealed that they enjoy the food that the facility offers and stated that if they inform staff that they want something different than what is listed on the menu they will prepare it for them. R2 stated that sometimes residents will cook meals themselves or will order food from outside of the facility. R2 had no concerns with facility staff following the menu. During the interview with S1 they stated that they try to follow the facility’s menu, but sometimes residents will request other foods than what is listed. S1 stated that they try to follow the menu as much as they can, but they will change the meal plans at the request of the residents. During the physical plant tour LPA observed the facility’s menu posted on the refrigerator for the next ten (10) weeks. During the visit on 01/22/2025 LPA confirmed that the meal R2 was served for dinner the previous night matched what was listed on the facility’s menu for the evening. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff are not following facility menu.” Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview was conducted. This report was reviewed with the Administrator and a copy was provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6