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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203050
Report Date: 11/21/2022
Date Signed: 11/21/2022 02:52:10 PM

Document Has Been Signed on 11/21/2022 02:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
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:
11/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rafael Lopez - Administrator TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility with emphasis on infection control practices and procedures. Upon arrival, LPA met with Administrator Rafael Lopez and explained the reason for the visit.

Facility has (3) resident bedrooms. (1) of the bedrooms are private resident room and the other (2) are shared. Hallway bathroom is designated for common use and there is a bathroom in room #3. Fire extinguishers were observed fully charged and last serviced in February of 2022.

At approx. 01:30pm, LPA toured the facility with Administrator The kitchen appeared to be relatively  clean at this time and the appliances and fixtures functional during the time of visit.  LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were observed stored in a a hallway closet to the left of the common bathroom. Closet was observed to be inaccessible to residents in care at this time. Medications, first aid kit and PPE were also observed stored in this closet. Laundry area was located next to the kitchen. Cleaning products were observed to be inaccessible at this time.

Dining room furniture appeared to be relatively clean and functional at the time of the visit. At 1:30pm, LPA observed (1) resident watching television in the living room. There was an extra freezer located in the living room, which stored residents personal foods. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident.  The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed three (3 ) bedrooms. Extra linen are kept in a cabinet in the hallway to the right of the bathroom. LPA observed a sufficient supply of linen and  personal hygiene supplies. Extra PPE was also observed stored in the closet as well. At approximately 1:45pm, LPA observed resident sleeping in bedroom #3.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/21/2022
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Continued from 809

LPA observed bathrooms to be relatively  clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom  between 105 - 120 degrees Fahrenheit.

The living room was  checked for cleanliness and furniture was checked for functionality during time of visit. Furniture appeared to be relatively clean and functional at this time.  Hallway closet by entry door was observed to store residents personal snacks. LPA observed  a 30 day supply of PPE stored easily in multiple locations throughout the facility.

Outdoor Area:  There was a shaded area with sufficient room for activities. LPA observed sufficient furniture designated for outdoor use. There are no bodies of water on the premises.  LPA did not observe any obstructions to emergency exits at this time. There was a detached building in the rear of the facility. LPA observed this to be the office. Resident files, and emergency food supplies were observed stored in this location as well.

The LPA spoke with Rafael regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate room #3 as a single isolation room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if there are any covid-19 concerns.  The facility’s policies and procedures as it pertains to infection control are adequate 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: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
LIC809 (FAS) - (06/04)
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