340300522-7-29-2021-27-AS-TTRG-C5DNVY-20210729104842

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 340300522
Report Date: 07/29/2021
Date Signed: 07/29/2021 10:48:51 AM

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 HOUSE		FACILITY NUMBER:	340300522
ADMINISTRATOR:	ROBERT GODFREY		FACILITY TYPE:	740
ADDRESS:	415 P STREET		TELEPHONE:	(916) 442-4906
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95814
CAPACITY:	41	CENSUS: 15	DATE:	07/29/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Assisted Living Manager, Kayla Frazier, LVN, Hazel Galicia, RN		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced on 07/29/2021 at 8:35 AM to conduct an annual inspection visit. Prior to entering the facility, LPA called the facility and spoke to Candace Kite, who informed LPA that the facility has no positive COVID-19 cases within the last 10 days. LPA met with Assisted Living Manager, Kayla Frazier, and explained the purpose of the visit. LPA toured the facility with Assisted Living Manager, Kayla Frazier and RN, Hazel Galicia on 07/29/2021 at 8:50 AM. Administrator Robert Godfrey holds current certification #6000615740 and renewal applications is pending. LPA inspected facility including common areas, resident units including bathrooms, kitchen, food storage areas, medication room, and laundry room to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. LPA measured hot water temperatures in resident rooms #512, #316, and #318. Hot water measured within the required range of 105-120 degrees Fahrenheit in all three rooms. LPA observed there to be a sufficient amount of perishable and non-perishable food supply on hand. Medications, toxins, and knives were inaccessible to residents. Smoke detectors are present in every room and throughout the facility. Facility also has carbon monoxide detectors. Fire extinguishers and first aid kit were up to date. LPA also conducted the infection control domain tool. Continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

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
	VISIT DATE: 07/29/2021

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The facility mitigation plan was submitted to CCLD, and it was approved on 5/7/2021. Facility has routine symptom screening checks for residents, staff, and visitors. The facility has a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan.

The following forms and documents were requested to be submitted within 15 days:
(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) Administrative Organization (LIC309)
(7) Control of Property

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview held and a copy of the report provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

LIC809 (FAS) - (06/04)

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