<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320464
Report Date: 11/12/2024
Date Signed: 12/04/2024 12:23:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/04/2024 and conducted by Evaluator Zina Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241104100324
FACILITY NAME:PIONEER CARE HOMEFACILITY NUMBER:
198320464
ADMINISTRATOR:BANZUELA ALVINFACILITY TYPE:
740
ADDRESS:3671 N PIONEER BLVDTELEPHONE:
(562) 343-1107
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:6CENSUS: 5DATE:
11/12/2024
UNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Alvin Banzuela, AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was inappropriately restrained.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/12/2024, at 9:35 AM, Licensing Program Analyst (LPA) Zina Brown and Licensing Program Manager (LPM) Janae Hammond initiated an unannounced complaint investigation regarding the allegation listed above. During the visit, LPA and LPM met with caregiver Marylou Santos, and later Administrator Alvin Banzuela arrived.

The investigation consisted of the following: On 11/12/2024, LPA and LPM interviewed Administrator (A1) via telephone, Staff # 1-3(S1 – S3) and Residents #1-4 # (C1 – C4). LPA was unable to interview Resident #5 due to communication barriers. LPA conducted residents and staff records review and files are incomplete.

On 11/12/2024, LPA and LPM did a facility plant tour and observed the following residents rooms #1- #5, bathrooms #1-2, living room, dining room and kitchen.

Continues on LIC 9099-C page
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 11-AS-20241104100324
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PIONEER CARE HOME
FACILITY NUMBER: 198320464
VISIT DATE: 11/12/2024
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
26
27
28
29
30
31
32
The investigation revealed the following:
Allegation: Resident was inappropriately restrained

On 11/12/2024, at 9:38 AM, LPA Zina Brown and LPM Janae Hammond interviewed Administrator (A1) Alvin Banzuela via phone regarding the above allegation.
  • A1 stated that he has provided verbal training for the use of gait belts/postural supports. However, he acknowledged that there is no documented training on file for the use of gait belts/postural supports.
  • A1 explained that clients use gait belts, which he believes are part of their wheelchairs and are buckled in front of the client.
  • A1 confirmed there are no physician orders for the use of gait belts.

On 11/12/2024, between 10:14 AM and 10:26 AM, LPA interviewed Staff #1-3 (S1-S3) regarding the allegation:
  • All three staff confirmed the use of gait belts for all clients and stated that the gait belts are buckled from behind the clients.
  • Two of the three staff confirmed receiving gait belt training prior to working at the facility.
  • One staff member confirmed receiving training upon hire.

Continues on LIC 9099-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20241104100324
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PIONEER CARE HOME
FACILITY NUMBER: 198320464
VISIT DATE: 11/12/2024
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
26
27
28
29
30
31
32
On 11/12/2024, between 9:59 AM and 11:51 AM, LPA interviewed Clients #1-4 (C1-C4). All four clients denied the allegations. However, two of the four clients confirmed the use of gait belts.

On 11/12/2024, all three staff demonstrated how gait belts are used on clients. The demonstration revealed that gait belts are buckled from behind the clients.

On 11/12/2024, at 10:50 AM, LPA reviewed the records for Clients #1-4. No doctor’s orders for the use of gait belts or postural supports were observed.

On 11/12/2024, at 11:00 AM, LPA reviewed the personnel records for Staff #1-3. No documentation of employee training was observed.



Substantiated: Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview conducted with Alvin Banzuela (Administrator) and copy of the report and appeal right were provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20241104100324
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: PIONEER CARE HOME
FACILITY NUMBER: 198320464
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
87468.1(a)(2)
1
2
3
4
5
6
7
. . .(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment
1
2
3
4
5
6
7
The licensee/administrator shall provide staff training on the proper use of gait belt. Training will be documented in the staff file & the copy of the training
8
9
10
11
12
13
14
Based on observation & interview, the facility staff is utilizing a gait belt that is buckled behind the resident which does not the resident to release them from chair.
8
9
10
11
12
13
14
will be submitted to the department by POC due date.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4