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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200131
Report Date: 02/18/2025
Date Signed: 02/18/2025 04:57:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/26/2024 and conducted by Evaluator Lori Alexander-Washington
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240926145843
FACILITY NAME:PATHWAY, THEFACILITY NUMBER:
079200131
ADMINISTRATOR:CARSWELL, JOHNFACILITY TYPE:
772
ADDRESS:550 PATTERSON BLVD.TELEPHONE:
(925) 938-8050
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:16CENSUS: 9DATE:
02/18/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:John Carswell, Campus AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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1. Staff did not prevent resident from engaging in physical altercations with other residents resulting in injuries.

2. Staff are not meeting residents needs.
INVESTIGATION FINDINGS:
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On 02/18/2025 at 11:45 AM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Campus Administrator, John Carswell, to deliver the findings of above allegations. LPA explained the purpose of the visit with Administrator.

During investigation, LPAs obtained the following documents: Staff Roster, Resident Roster, Staff Schedule (Aug '24-Sep '24), LIC 500 and R1's-R8's Admissions Face Sheet, Physician's Reports, Medication Lists, MARs, Progress Notes for August-September '24 and copy of Incident Reports if applicable, face sheet, Physician's Reports, progress notes, Appraisal Needs and Services and Unusual Incident Reports if applicable

LIC9099-C Continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
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 5
Control Number 15-AS-20240926145843
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PATHWAY, THE
FACILITY NUMBER: 079200131
VISIT DATE: 02/18/2025
NARRATIVE
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LIC9099-C (Page 2)

Allegation: Staff did not prevent resident from engaging in physical altercations with other residents resulting in injuries.
Finding: Substantiated

During the investigation, the LPA conducted interviews of witnesses (W), staff (S), and clients (C).

On 09/27/2024 LPA interviewed W1. W1 stated that C5 gets into physical altercations with other residents and that the administrator does not do anything about the physical altercations amongst the residents. W1 stated that C5 has been in physical altercations with staff as well as has hit a staff. W1 stated that C1 and C3 have been in physical altercations as well as C3 spitting on C1. W1 stated that residents get jumped, sustain black-eyes and bloody injuries. W1 stated that there was no behavioral crisis intervention enforced by administration.

On 10/14/2024 LPA interviewed W2. W2 stated that they know of residents punching another resident in the face and that the resident was traumatized after the incident.

On or around 09/30/2024 LPA interviewed S3, S4, S5, S6 and S7. S3, S4, S5, S6 and S7 all stated that there have been physical altercations among the residents. S3, S4, S5, S6 and S7 all stated that physical altercations included residents spitting, swinging punches, throwing chairs, signs and liquids at other residents and staff. S3, S4, S5, S6 and S7 all stated that training does not cover de-escalation with physical violence between residents.

LIC9099-C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20240926145843
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PATHWAY, THE
FACILITY NUMBER: 079200131
VISIT DATE: 02/18/2025
NARRATIVE
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LIC9099-C (Page 3)

S3, S4, S5, S6 and S7 all stated that they are not allowed to touch residents, and the most that they can do is talk to the residents. S3, S4, S5, S6 and S7 stated that it took approximately 45 mins to an hour to intervene on the physical altercations with residents. S3, S4, S5, S6 and S7 all stated that they cannot activate mental health intervention by mental health professionals unless approved by administrator.

On 10/04/2024 LPA interviewed C1 and C2. C1 stated that C3 hit C1 on the back with a “Wet Floor” sign. C1 stated that C1 called the Pleasant Hill Police Department (PHPD) who responded and took a statement. C1 stated that their back was red and was hurting. C2 stated that C4 hit them in the face while both C2 and C4 were outside in the smoking area. C2 stated that they went looking around the facility for help, knocking on doors for staff and was told by one (1) staff to wait till they are back from lunch break. Meanwhile, C2 stated that C4 continued to follow them in the facility building while verbally and physically assaulting C2. C2 stated they called 911 and PHPD came out to the facility and called the ambulance to transport C2 to the Emergency Department (ED). Both C3 and C4 were not available for interviews. C3 moved out and C4 was out in the community.









LIC9099-C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20240926145843
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PATHWAY, THE
FACILITY NUMBER: 079200131
VISIT DATE: 02/18/2025
NARRATIVE
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LIC9099-C (Page 3)

Allegation: Staff are not meeting residents’ needs.
Finding: Substantiated

On or around 09/30/2024 LPA interviewed W1, W2, S3, S4, S5, S6 and S7. S3, S4, S5, S6 and S7 all stated that there are no bath towels for residents and that residents come asking for shower and hygiene supplies every other day. W1 stated that the residents’ mental health declines for not keeping up hygiene. S3, S4, S5, S6 and S7 all stated that there is no direct training for de-escalation; the only training is through Pro-Act. S3, S4, S5, S6 and S7 all stated when/if a resident gets physical or need a higher-level mental health professional to intervene, they are not allowed to call the crisis team. S3, S4, S5, S6 and S7 all stated that there is not enough staff on shifts, including nights and weekends to supervise residents. S3, S4, S5, S6 and S7 all stated that the schedule on paper reflects coverage but if any staff calls-out there isn’t another staff to cover. S3, S4, S5, S6 and S7 all stated that the program will only have one (1) staff scheduled for the weekend. W2 stated that The Pathway has big turnover, they're short staff and when they go to The Pathway, it's hard to find any staff around. LPA observed on 09/27/2024 that there were not enough bath towels and bed linens for the capacity of residents at the program. LPA observed limited sizes of towels and bed linens in the facility’s linen closet and laundry room.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20240926145843
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PATHWAY, THE
FACILITY NUMBER: 079200131
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2025
Section Cited
CCR
81072(a)(2)
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81072 Personal Rights
(a) Each client shall have personal rights which include, but are not limited to, the following:(2) To be accorded safe...comfortable accommodations...to meet his/her needs.

This requirement is not met as evidenced by:
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Administrator agreed to conduct a live in-person re-training on de-escalation skills and will send a copy of an synopsis of training course with an attendance sign-in sheets to CCLD by POC due date.
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Based on interview and record review, the licensee did not comply with the section cited above in by not providing a safe accomodations for residents when physical altercations occur between residents in care which poses a potential health, safety or personal rights risk to persons in care.
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Type B
03/18/2025
Section Cited
CCR
81088(i)(4)(A)
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81088 Fixtures, Furniture, Equipment, and Supplies
(i) The licensee shall ensure provision to each client...supplies necessary for personal care and maintenance of personal hygiene....

This requirement is not met as evidenced by:
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Administrator agreed to order/purchase bath towels and hygiene produts including but not limited to products for bathing/showering and feminine hygiene products.
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Based on interview and observation, the licensee did not comply with the section cited above in by not having enough hygiene supplies including but not limited to bath towels (all sizes), clean bed linens, clean blankets and hygiene products available for residents in care which poses a potential health, safety or personal rights risk to persons in care.
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LPA observed towels (all sizes) stored in storage closets. Along with other hygiene products stored in storage closets and the medication room.

Deficiency cleared during visit.
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: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5