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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003969
Report Date: 03/14/2022
Date Signed: 03/14/2022 01:05:19 PM

Document Has Been Signed on 03/14/2022 01:05 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PIONEER HOMES OF CALIFORNIAFACILITY NUMBER:
306003969
ADMINISTRATOR:GLADYA IDIO SENCIDAFACILITY TYPE:
735
ADDRESS:2041 W. CAROLYN PLACETELEPHONE:
(562) 424-4287
CITY:LONG BEACHSTATE: CAZIP CODE:
90810
CAPACITY: 4CENSUS: 4DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Estrellita Tapawan Staff/RONNEL AGLIAM Administrator TIME COMPLETED:
01:00 PM
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On 03/14/22 Licensing Program Analyst (LPA) Jade Jordan conducted an unannounced annual inspection visit, with an emphasis on infection control. LPA was met by staff Estrellita Tapawan, and the purpose of the visit was explained. Upon entry LPA was screened for Covid19, and temperature was documented.


The facility is a single story home located in a residential neighborhood. The home consists of 4 client bedrooms, 1 staff room, 2 bathrooms, living room, kitchen, dining area, laundry area, detached garage with supply room and 1 staff bathroom. LPA observed all client bedrooms to contain the required furniture, bedding, closet space and lighting. The bathrooms contained working toilets, water faucets and shower, all were clean and free of mold/mildew. The water temperature measured 108.6. F. LPA observed required postings including emergency disaster plan and facility sketch. The laundry area contained a working washer/dryer and cabinets contained, hygiene supplies, cleaning agents and personal care items which were locked and inaccessible to the clients in the outside storage in the locked garage. LPA observed kitchen to contain working appliances and refrigerator contained food appropriated sealed, covered and dated. The food supply contained an adequate supply of perishables and non-perishables that met title 22 guidelines.
The last fire drill was conducted on 02/17/22, Fire extinguisher was serviced in January of 2022. LPA observed functional smoke detectors.

Active Administrators License is on display and does not expire until 03/08/23
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PIONEER HOMES OF CALIFORNIA
FACILITY NUMBER: 306003969
VISIT DATE: 03/14/2022
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LPA Reviewed 2 client files, Mars, PNI, and 2 staff files. All files had the required documentation, including health screenings.

The outside grounds were clean and clear of debris/obstruction. No bodies of water were observed on the premises.

The facility is following their mitigation plan. Full supply of PPE were observed over the minimum of 30 days.
(Faceshields, gowns, gloves, paper towels, soap, disinfectant, sanitizer, n95 masks, surgical masks, and trashcans with lids) The facility tracks and logs the temperature of all staff, visitors and residents. All residents and staff are fully vaccinated, including boosters. Proof of vaccination was kept on file in the client and staff records. N95 fit testing was also provided to staff in addition to staff Covid trainings. Multiple Covid 19 postings including good hygiene practices were posted throughout the facility.

An Exit interview was conducted, and copy of this report was provided. No deficiencies were issued during this visit.


SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC809 (FAS) - (06/04)
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