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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320464
Report Date: 11/12/2024
Date Signed: 11/12/2024 03:03:00 PM

Document Has Been Signed on 11/12/2024 03:03 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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: 5DATE:
11/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Alvin Banzuela, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 11/12/2024 at 9:35am, Licensing Program Analyst (LPA) Zina Brown and Licensing Program Manager (LPM) Janae Hammond conducted an unannounced case management deficiencies.

During the complaint investigation, LPA observed residents and staff records are incomplete, Staff #3 is not associated to the facility and Resident #2 - Resident #5 have bed rails but there are no physician orders on file. The facility staff are using gait belts for residents #1- resident #5 there are no physicians order.

Civil penalties assessed and the decencies cited under California Code of Regulation Title 22, Division 6, Chapter 8 are being cited on the LIC 809-D.

Exit interview conducted with Alvin Banzuela, Administrator and a copy of this report was provided with appeal rights.
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.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 11/12/2024 03:03 PM - It Cannot Be Edited


Created By: Zina Brown On 11/12/2024 at 12:51 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
, 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 A
11/13/2024
Section Cited
CCR
87355(e)(2)

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Request a transfer of a criminal record clearance as specified in Section 87355(c) or
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The licensee/administrator will associated Staff #3 in guardian or submit criminal record transfer request to CCL by POC date.
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. . Based on records review, Staff #3 is not associated to the facility poses as a health and safety risk to residents in care.
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Type B
12/04/2024
Section Cited
CCR87608(a)(3)

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A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
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The licensee/administrator will obtain physician order and submit a copy to the department by POC date.
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Based on records review and observation, Resident #2-#5 have half bed rails but no physician order on file which poses as a personal rights risk to residents in care.
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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: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


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/12/2024 03:03 PM - It Cannot Be Edited


Created By: Zina Brown On 11/12/2024 at 01:04 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
, 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
12/12/2024
Section Cited
CCR
87506(a)

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The licensee shall ensure that a separate, complete, & current record is maintained for each resident in the facility. . .
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The licensee/adminstrator will ensure all resident records are complete and ready for licensing review by POC due date.
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Based on records review and observation, Resident #1 - #5 records were incomplete which poses as a health and safe risk to residents in care
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Type B
12/12/2024
Section Cited
CCR87412(a)

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The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. . .
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The licensee/adminstrator will ensure all staff records are complete and ready for licensing review by POC due date.
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Based on records review and observation Staff #1-Staff #3 personnel records were incomplete which poses a potential health and safety risk to the residents in care
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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: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


LIC809 (FAS) - (06/04)
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