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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203050
Report Date: 11/07/2023
Date Signed: 11/07/2023 03:57:17 PM

Document Has Been Signed on 11/07/2023 03:57 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:
11/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Rafael LopezTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 12:45pm. Upon arrival, the LPA met with staff and explained the reason for the visit.  Administrator Rafael Lopez arrived shortly after.

At approx. 1:15p.m., the LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted:

The LPA inspected the kitchen/food service area at 1:15 p.m. Knives and sharp objects are stored inaccessible to clients in the medication closet located to the left of the bathroom. Kitchen appliances appeared to be   in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates.

At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 02/22/2023. The LPAs observed required postings on bulletin boards located in the office area.  The LPA’s observed an adequate supply of emergency food and water. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed.

The LPAs observed the resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPAs observed a sufficient supply of towels and linens.

The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water  measured between 117.6 degrees Fahrenheit. 
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: 11/07/2023
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Continued from 809

LPA reviewed Resident Records and Personnel Records between 2pm - 3pm
Five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order at this time. Five (5 ) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order at this time.  The last fire drill was conducted on 09/07/2023.

Medications review began at approximately 3pm.  The medications are centrally stored in a med room closet located to the left of the bathroom. Medications are stored in cassettes / pill boxes, which is their originally stored container provided by the pharmacy.  Approximately four (4) cassettes arrive at the beginning of the month for each client.  Administrator stated staff do not administer medications as staff only provide the clients with their own cassette / pill box in order for client to administer their medication themselves.  Medications are properly documented on the centrally stored medications and destruction record.

Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. 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 a single isolation room if the facility has a confirmed case of a communicable disease. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

The LPA conducted interviews with two (2) staff members and two (2) residents between 1pm - 4:00pm.

During today’s visit, the LPAs obtained copies of the following documents: Census and staff schedule.

Exit interview conducted and report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC809 (FAS) - (06/04)
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