340300522-1-10-2023-27-AS-TTRG-CMXVXM-20230110154945

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 340300522
Report Date: 01/10/2023
Date Signed: 01/10/2023 03:49:51 PM

Document Has Been Signed on 01/10/2023 03:49 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	PIONEER HOUSE		FACILITY NUMBER:	340300522
ADMINISTRATOR:	FRAZIER, KAYLA		FACILITY TYPE:	740
ADDRESS:	415 P STREET		TELEPHONE:	(916) 442-4906
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95814
CAPACITY:	41	CENSUS: 8	DATE:	01/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Kayla Frazier, Administrator		TIME COMPLETED:	04:15 PM

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 to conduct an annual inspection visit on 1/10/2023. LPA met with Business Office Manager Anna Pierson and explained the purpose of the visit. Administrator Kayla Frazier arrived a bit later. Administrator Certificate # 6060657740 and expires on 11/18/2023. There are currently 8 residents who reside at this facility. 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. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, laundry rooms, and medication room 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 room #: 218, 322 and 515 were 113.0 which is within the required range of 105-120 degrees Fahrenheit. The temperature inside the facility measured at 72F which was within the required range of 68-85F. 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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

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: 01/10/2023

NARRATIVE

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LPA requested resident and staff files for review. LPA reviewed (3) resident files and (3) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA observed staff S1, S2 and S3 first aid and cpr certificates had expired.

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 California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is being cited. See 809D for citation. Failure to correct the deficiency by the noted due date may result in a penalty being assessed.

Exit interview conducted and copy of report provided. Appeal rights given.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/10/2023 03:49 PM - 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: 01/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General. Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Staff S1, S2 and S3 first aid and cpr certificates had expired. This poses a potential health and safety risk residents in care.
	POC Due Date: 01/17/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator shall enroll staff in a first aid class and send proof of enrollment to CCL by 1/17/2023. Upon completion of course please send proof of first aid card to CCL. Proof of first aid shall be received by CCL within 30 days of today's date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

LIC809 (FAS) - (06/04)

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