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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700263
Report Date: 02/11/2022
Date Signed: 02/11/2022 11:37:34 AM

Document Has Been Signed on 02/11/2022 11:37 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 CARE HOMEFACILITY NUMBER:
392700263
ADMINISTRATOR:RONQUILLO, EUNICEFACILITY TYPE:
735
ADDRESS:9474 PIONEER CIRCLETELEPHONE:
(209) 910-9014
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 6CENSUS: 4DATE:
02/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Eunice RonquilloTIME COMPLETED:
11:40 AM
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On 2-11-22 at 9:58am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Eunice Ronquillo and explained the purpose of the visit.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed adult residential facility with a current census of 4. Facility has 4 bedrooms, 2 bathrooms. There is a formal living room and TV room with a dining area off the kitchen. The facility has an approved COVID Mitigation plan LIC 808 form in place. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. Complaint posters and resident rights posted.

Water temperature reads 106.1*F in the bathroom and room temperature reads 69*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher fully charged. Facility has an emergency food and water kit. Observed staff training inservices documentation including 9-1-1 emergency calls. 9-1-1 emergency call training was completed 12/26/21. LPA reviewed 8 staff charts. All staff are COVID-19 vaccinated.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was held with Eunice Ronquillo and a report was given to Eunice Ronquillo.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2022
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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