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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700263
Report Date: 01/18/2022
Date Signed: 01/18/2022 10:48:08 AM

Document Has Been Signed on 01/18/2022 10:48 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:
01/18/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Licensee/Administrator - Eunice RonquilloTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) T. White conducted unannounced Legal/Non-Compliance visit at facility. LPA met with Licensee/Administrator, Eunice and James Ronquillo. LPA explained the purpose of visit. The facility is on a three year probation and will have increased unannounced monitoring.

LPA reviewed the following documents:

In-Service Training
Fire Drills - 01/26/2022 Facility Sketch Review and Discussion
Emergency and Disaster Drills - 11/02/2021 Review Emergency Shut Off and Locations

Department of Social Services Survey Binder:
07/07/2021 Annual Inspection
Current LIC 610-D Emergency Disaster Plan 2/28/21
LIC 308 - Designation of Administrator - 3/1/21
LIC 309 - Administrative Organization - 3/1/21
Personal Rights
Activities for each Client
Description of facility and schedule
Copy of Stipulation - 2/24/21
911 Calling Policy
Emergency Procedures
Incident Reporting

Continued on 809-C.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2022
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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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 CARE HOME
FACILITY NUMBER: 392700263
VISIT DATE: 01/18/2022
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Continued from 809 Page 2

Department of Social Services Survey Binder:
Non-Compliance Conference 11/14/2019

Compliance Binder:
Personal Rights
Technical Support Program Engagement Summary - 4/12/21

Staff In-Service Training
Observations of clients, when to obtain medical emergency for a client, duty of independent caregivers for obtaining emergency care for clients, abuse training, mandated reporting requirements, and personal rights. Demonstration, SIR reporting, Unusual Incidents, Discussion, Scenarios, Questions and Answers, and Examinations. 3/7/21 (8:30 AM - 9:30 AM, 9:30 AM - 10:30 AM,10:30 AM - 11:30 AM), 4/24/2021 (3:30 PM - 4:30 PM), 4/25/21 (11:00 AM - 11:30 AM, 3:00 PM - 3:30 PM, 3:30 PM - 4:30 PM), 5/23/21 (4:00 PM - 5:00 PM), and 6/25/21 (2:30 PM - 3:30 PM) 07/23/2021 (3:00 PM - 4:00 PM) 08/27/2021 (10:00 AM- 11:00 AM) 09/25/2021 (2:00 PM - 3:00 PM) 10/25/2021 (3:00PM- 4:00PM) 11/25/2021 (10:00 AM- 11:00 AM) 12/26/2021 (1:00 PM- 2:00 PM)

No deficiencies cited on today's date.

Exit interview with Licensee/Administrator and copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
LIC809 (FAS) - (06/04)
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