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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700263
Report Date: 02/13/2025
Date Signed: 02/14/2025 09:36:20 AM

Document Has Been Signed on 02/14/2025 09:36 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PIONEER CARE HOMEFACILITY NUMBER:
392700263
ADMINISTRATOR/
DIRECTOR:		RONQUILLO, EUNICEFACILITY TYPE:
735
ADDRESS:9474 PIONEER CIRCLETELEPHONE:
(209) 910-9014
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 6CENSUS: 4DATE:
02/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Aleen Querida and Eunice RonquilloTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Unannounced Annual Licensing visit made out to this facility on 02/13/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver, Alenn Querida, at this time. A brief interview was conducted with the facility caergiver at this time.
This LPA requested that the facility caregiver go ahead and contact the facility designated Administrator, Eunice Ronquillo, to inform her that CCL was present at this time. She arrived later to this facility while this LPA was conducting this annual visit.
This facility is licensed to serve up to (6) Non Ambulatory residents at any given time.
Current census was 4 residents, of which (2) of them, were out of the facility at this time at their respective day programs.
Tour of this facility was conducted.
A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were observed to be locked and made inaccessible to the residents at this time.
Cleaning agents, bleach, and other supplies were observed to be locked and made inaccessible to the residents at this time.
A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times.
Medication cabinet, located in the kitchen cabinet, was reviewed. Policies and procedures involving handling, dispensing, and documentation of the resident medications were discussed with the facility designated staff member at this time. A review of the facility Medication Administration Record and dispensing log was conducted.
Medication cabinet was observed to be locked and made inaccessible to the residents at this time.
Living room, dining area, and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time and able to meet the needs of the residents.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PIONEER CARE HOME
FACILITY NUMBER: 392700263
VISIT DATE: 02/13/2025
NARRATIVE
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A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the resident restroom was conducted.
Hot water temperature was taken to make sure that it measured within the allowed range of 105-120 degrees at all times.
Laundry room, located prior to the garage door exit, was toured. Cleaning supplies, detergents, and bleach were observed to be locked and made inaccessible to the residents at this time.
Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the garage area was conducted. Additional food storage unit was present and in functional order at this time.
First aid kits were observed to be present and contained all of the required components at this time.
Fire extinguishers were observed to have been purchased on 07/25/2024 from the local Home Depot store and observed to be in compliance at this time.
Administrator certificate for Eunice Ronquillo was observed to have an expiration date of 02/15/2025 with certificate #7010343735. All updated forms and documents have been submitted to renew at this time.
A tour of the exterior grounds for this facility was conducted. A review of the facility perimeter fence, side gates, and exits was conducted.
A review of (4) facility resident files was conducted and noted on the following LIC 858.
A review of (4) facility staff files was conducted and noted on the following LIC 859.

This LPA requested that this facility, and its representative, update the following forms and submit them into CCL for review by this LPA:

LIC 308, LIC 400, LIC 500, LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal rights were reviewed and a copy was printed and given to the facility designated Administrator at this time.
Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/14/2025 09:36 AM - It Cannot Be Edited


Created By: Charlie Yang On 02/13/2025 at 12:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PIONEER CARE HOME
FACILITY NUMBER: 392700263

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [4] facility personnel records did not have a completed health screening with proper TB clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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The facility designated Administrator stated that all facility personnel records will be reviewed to make sure that all of them contain required health screening and proper TB clearance at all times. A statement of correction, along with copies of the updated health screening reports, will be completed and submitted into CCL by the due date.
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that there was not a sufficient supply of non perishable food items present at this facility to meet the 7-day requirements at all times which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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The facility designated Administrator stated that nonperishable food items will be purchased to maintain the required 7-day supplies at all times. A statement of correction, along with copies of the receipt(s) for the updated food items purchased, will be completed and submitted into CCL by the due date.
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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/14/2025 09:36 AM - It Cannot Be Edited


Created By: Charlie Yang On 02/13/2025 at 12:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PIONEER CARE HOME
FACILITY NUMBER: 392700263

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)
Client Records
(b) Each record must contain information including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [3] out of [4] facility resident records were incomplete missing required forms and documents such as the SPV and medical assessment documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2025
Plan of Correction
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The facility designated Administrator stated that all facility resident records will be reviewed to make sure that all of them contain the required health screening forms and proper documents at all times. A statement of correction, along with copies of the updated health screening report and required documents, will be completed and submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2025


LIC809 (FAS) - (06/04)
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