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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320464
Report Date: 06/13/2024
Date Signed: 06/13/2024 12:06:08 PM

Document Has Been Signed on 06/13/2024 12:06 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PIONEER CARE HOMEFACILITY NUMBER:
198320464
ADMINISTRATOR/
DIRECTOR:		BANZUELA ALVINFACILITY TYPE:
740
ADDRESS:3671 N PIONEER BLVDTELEPHONE:
(562) 343-1107
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 6CENSUS: 0DATE:
06/13/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator - Alvin BanzuelaTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 06/13/2024 at around 10:00 AM Licensing Program Analyst (LPA) Leandro conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA met with Administrator Alvin Banzuela.

On 03/01/2024 an application was submitted to CCLD, for Initial license for a Residential Care Elderly Facility to serve adults ages 66 and above. The facility was approved for a capacity of 8 people. There may be 6 non-ambulatory residents and 2 bedridden residents in this facility. The facility is a one-story house located on a residential street. The facility is composed of 4-bedrooms, 2-bathrooms, 1-office, 1-kitchen/common room area, 1-dining room, 1-backyard deck, 1-attached garage. LPA conducted a review of the Physical Plant, Bedrooms, Bathrooms, Supplies, Food Service, Medications, Records, Administration, Activities, Pe-Licensing Checklist and Component III Orientation.

MEDICATIONS
There is a locked centralized storage area for resident medications.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PIONEER CARE HOME
FACILITY NUMBER: 198320464
VISIT DATE: 06/13/2024
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PHYSICAL PLANT
Facility is clean, sanitary, and in good repair. Protective devices are in place to include nonslip material on rugs. Indoor and outdoor passageways, stairways, inclines, ramps, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Fireplaces and open-faced heaters are inaccessible to residents. Stairways, inclines, ramps, open porches, and areas of potential hazard are well-lit and equipped with sturdy hand railings. Fire Alarms and Smoke alarms operate properly. Carbon monoxide detectors operate properly.

BEDROOMS
Halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings are not being used as resident bedrooms. Resident bedrooms are large enough to allow for easy passage and to accommodate furniture and assistive devices such as wheelchairs, walkers, or oxygen equipment. No resident bedroom is a passageway to another room, bath or toilet. There is a bed for each resident with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair. Mattresses and pillows are flame-retardant. There is dresser and closet space for each resident that includes at least two (2) drawers or eight (8) cubic feet of dresser space per resident. There is a chair and lamp for each resident and at least one (1) nightstand per two (2) residents.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PIONEER CARE HOME
FACILITY NUMBER: 198320464
VISIT DATE: 06/13/2024
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BATHROOMS
There is at least one (1) toilet and washbasin per six (6) residents, family, and personnel. There is at least one (1) shower or bathtub per ten (10) residents, family, and personnel. Hot water temperature is between 105-120 degrees Fahrenheit. Bathroom is located near resident bedrooms. There are nightlights in the hallways outside non-private bathrooms.

SUPPLIES
There are resident personal hygiene supplies to include feminine napkins, soap, toothpaste, toilet paper, and comb. There is a sufficient supply of clean linens to permit weekly changing or more of resident top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths.

FOOD SERVICE
Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0 degrees Fahrenheit. Refrigerator is a maximum of 45 degrees Fahrenheit. A seven (7) day supply of non-perishable food is present. There are sufficient amounts of tableware, tables, dishes, and utensils. There are sufficient amounts of equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PIONEER CARE HOME
FACILITY NUMBER: 198320464
VISIT DATE: 06/13/2024
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RECORDS
There is confidential storage of personnel records at the facility. There is confidential storage of resident records at the facility.

ADMINISTRATION
The emergency exiting plan and emergency phone numbers are posted. Resident Personal Rights are posted. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings.

ACTIVITIES
An activities calendar is posted. There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to residents for visitors. There are activity supplies to include newspapers, magazines, and a variety of reading material.

MISCELLANEOUS
There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to residents. Emergency lighting and supplies to include flashlights with batteries. Vehicles used to transport residents are in safe operating condition.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PIONEER CARE HOME
FACILITY NUMBER: 198320464
VISIT DATE: 06/13/2024
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PRE-LICENSING CHECKLIST
Completed by licensee and reviewed by LPA.

COMPONENT III
Information was provided about how to operate the facility within substantial compliance.

An exit interview was conducted, and a hard copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to the applicant.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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