198203050-11-8-2024-29-AS-SURA-DAU7H2-20241108204000

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198203050
Report Date: 11/08/2024
Date Signed: 11/08/2024 08:40:48 PM

Document Has Been Signed on 11/08/2024 08:40 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PIONEER HOME		FACILITY NUMBER:	198203050
ADMINISTRATOR/ DIRECTOR:	RAFAEL LOPEZ		FACILITY TYPE:	736
ADDRESS:	7402 HASKELL AVE.		TELEPHONE:	(818) 787-2403
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY: 6		CENSUS: 4	DATE:	11/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:10 PM
MET WITH:	Esmeralda Puente		TIME VISIT/ INSPECTION COMPLETED:	04:15 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit at 12:10 p.m. Upon arrival, the LPA met with staff and explained the reason for the visit. Assistant Administrator (AD) Esmeralda Puente arrived thereafter.

The LPA and the staff 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.

COMMON AREAS: At the time of the visit, living room and kitchen room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 70 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The two (2) fire extinguishers were fully charged and were last serviced on 02/02/2024. The LPA observed required postings throughout the common space, with the exception of the Emergency Disaster Plan (LIC 610) which needs to be updated and posted in a visible place.

KITCHEN: Knives and sharp objects are stored inaccessible to clients.Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and the non-perishable food, which is located in the office area. Refrigerator and food pantry were checked for proper labels and expiration dates. The washer and dryer are adjacent to the kitchen area. Cleaning supplies were observed to be locked.

BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three designated residents’ rooms. There was a linen closet in the hallway with extra towels and linens.

Continues on LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PIONEER HOME	FACILITY NUMBER: 198203050
	VISIT DATE: 11/08/2024

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BATHROOMS: Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water measured at 118.4 degrees Fahrenheit.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water were noted.

RECORDS: Records review began at 1:21 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate on-going training. All files were in order. Administrator agreed to email the LPA a current Fire Drill log and a Client Roster (LIC 9020).

MEDICATIONS: Medications review began at 2:10 p.m.; medications are centrally stored and locked in a cabinet in the hallway next to the bathyroom; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record, however for three out of three residents (Resident #1, Resident #2, Resident #3), the pill count was off during the medication audit.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

INFECTION CONTROL: 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 COVID-19.

The LPA reviewed the following documents:

- LIC500 Personnel Report

Citations were issued. Exit interview conducted. A copy of the report and Appeal Rights were issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/08/2024 08:40 PM - It Cannot Be Edited

Created By: Sandra Urena On 11/08/2024 at 03:53 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PIONEER HOME	FACILITY NUMBER: 198203050
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

The Licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on a medication audit, the licensee did not comply with the section cited above as 3 out of 4 resident medication pill count was not concurring with documentation which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/15/2024
	Plan of Correction
1 2 3 4	Administrator will request training from a professional entity to provide medication training. Administrator will submit paperwork as proof to CCL indicating the training was completed by the due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Kasandra Lopez

LICENSING EVALUATOR NAME:

Sandra Urena

LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

LIC809 (FAS) - (06/04)

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