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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340300522
Report Date: 11/15/2022
Date Signed: 11/15/2022 10:42:25 AM


Document Has Been Signed on 11/15/2022 10:42 AM - 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, 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: 9DATE:
11/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Kelly ChowTIME COMPLETED:
11:00 AM
NARRATIVE
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On 11/15/22 at 9:40am, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced case management visit to address concerns with facility administration. LPA met with facility representative Kelly Chow and stated the purpose of the visit.

As of today, 11/15/22, the facility has not had a qualified administrator appointed to oversee the facility and approved by the department. Moreover, no documents have been provided to the department to approve a new administrator. LPA advised facility representative that they may need to identify another individual to be the Administrator due to the facility representative has yet to submit required training for certification. LPA advised that certification approval may take several months due to department backlog of applications.

The following deficiencies are cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with the facility representative. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
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 2


Document Has Been Signed on 11/15/2022 10:42 AM - It Cannot Be Edited

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: 11/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/16/2022
Section Cited

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87405(a) Administrator - Qualifications and Duties. All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by:
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Based on interviews and records review, the licensee did not ensure the facility has an active certified Administrator. Staff S1 was appointed as Administrator without active administrator certification and CCL approval. 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: 11/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2