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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340300522
Report Date: 11/19/2020
Date Signed: 11/19/2020 05:51:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PIONEER HOUSEFACILITY NUMBER:
340300522
ADMINISTRATOR:ROBERT GODFREYFACILITY TYPE:
740
ADDRESS:415 P STREETTELEPHONE:
(916) 442-4906
CITY:SACRAMENTOSTATE: CAZIP CODE:
95814
CAPACITY:41CENSUS: 19DATE:
11/19/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Robert Godfrey, Executive DirectorTIME COMPLETED:
05:10 PM
NARRATIVE
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At around 4:30 PM, Licensing Program Analyst (LPA) Michael Hood contacted the facility via telephone to discuss deficiencies observed during a complaint investigation (#27-AS-20200213092524). Notification of deficiencies are delivered via telephone as a pre-cautionary measure due to COVID-19. LPA explained the purpose of the call to Executive Director, Robert Godfrey.

During the investigation, LPA Melody Claussen observed that though the facility admits and retains residents with a dementia diagnosis, the facility’s plan of operation does not indicate how it will ensure the health, safety, and personal rights of those residents in care. On the current plan of operation under section 11 on page 26, it states, “Dementia Special Care: Insert specific plans for dementia unit – may modify and use the dementia training from #6 above.”

Due to the information above, per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 809-D page.

An exit interview was conducted with the Executive Director via telephone and a copy of this report and Appeal Rights will be provided to the facility via email. This facility shall sign and return a copy to CCLD by mail and print a copy to be retained by the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PIONEER HOUSE
FACILITY NUMBER: 340300522
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/25/2020
Section Cited

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87208 - Plan of Operation

A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b).
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This requirement is not met as evidenced by: Based on record review, facility is retaining residents with dementia but facility does not include dementia care in plan of operation. This poses a potential safety risk to the residents in care.
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Also, plan of operation should include safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
Administrator will send an updated plan of operation to CCLD by POC due date 11/25/2020.

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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: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2020
LIC809 (FAS) - (06/04)
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