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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340300522
Report Date: 01/06/2022
Date Signed: 01/06/2022 12:18:33 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:DAVID SHELLHAMERFACILITY TYPE:
740
ADDRESS:415 P STREETTELEPHONE:
(916) 442-4906
CITY:SACRAMENTOSTATE: CAZIP CODE:
95814
CAPACITY:41CENSUS: 12DATE:
01/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:David ShellhamerTIME COMPLETED:
12:30 PM
NARRATIVE
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On 1/6/2022 at 9:05 am, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. Prior to entering the facility, LPA Truong called and spoke to the administrator, who confirmed there are no active COVID cases in the facility. LPA met with Administrator David Shellhamer and explained the purpose of today’s visit.

Administrator holds current certification #6040629740 and expires on 3/28/2022. There are currently 12 residents who reside at this facility. LPA toured the facility with David Shellhamer on 1/6/2022 at 9:20 am.

LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, laundry rooms, medication room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is 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. Hot water measured in the resident’s bathroom room #218 is 122.0 and room #220 is 123.1 degrees Fahrenheit which are not within the required range of 105-120 degrees Fahrenheit. 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 and water sprinklers are present in every room and throughout the facility. 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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: 01/06/2022
NARRATIVE
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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. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan.

Administrator was informed to send updated copies of the following documents to CCL 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) LIC309 Administrative Organization

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were cited on 809-D. An exit interview was held, a copy of this report, 809-D and Appeal Rights were provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 01/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/07/2022
Section Cited

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87303(e)(2) Maintenance and Operation. Hot water provided for the use of residents shall be maintained between 105 and 120 degrees F.
This requirement is not met as evidenced by:
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Based on LPAs observation, the licensee did not maintain water temperature between 105 and 120 degrees Fahrenheit. Hot water measured in the resident’s bathroom room #218 was 122.0 and room #220 was 123.1 degrees Fahrenheit. This poses an immediate health and safety risk to residents in care.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3