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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200131
Report Date: 11/02/2022
Date Signed: 11/02/2022 12:31:40 PM

Document Has Been Signed on 11/02/2022 12:31 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:PATHWAY, THEFACILITY NUMBER:
079200131
ADMINISTRATOR:TRAVIS CURRANFACILITY TYPE:
772
ADDRESS:550 PATTERSON BLVD.TELEPHONE:
(925) 938-8050
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 16CENSUS: 13DATE:
11/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Nicole Paiste, Program Administrator
Kenneth Bullock, Program Director		TIME COMPLETED:
01:00 PM
NARRATIVE
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On 11/02/22 at 10:30AM Licensing Program Analysts (LPAs) J. Sampair and D. Panlilio arrived unannounced to conduct a case management visit on this date to follow-up on two incident reports that were faxed to CCL on 10/27/22 and 10/31/22. LPAs met with Program Administrator (PA) & Program Director (PD) and explained the purpose of the visit.

Based on record reviews and interviews during today’s visit, client (C1) was first admitted at the facility on 10/12/22. On 10/22/22 at approximately 5PM, staff (S1) observed client’s (C1) unauthorized absence from the facility during a welfare check. C1 did not sign out or notify staff of his departure. On 10/22/22 at approximately 11:59PM, staff filed a report with the local police department (Case# 22-3482). Review of C1's physician's report show C1 can leave the facility unassisted.

PD stated that on 10/28/22 he received a text message from C1’s family member stating that the police notified the other sister that he was deceased. PA also stated that C1’s co-conservator (POA1) informed her that C1 died in a San Francisco jail.
On 10/31/22, the San Mateo coroner’s office confirmed that C1 passed away on 10/27/22.

Continued on next page, LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2022
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PATHWAY, THE
FACILITY NUMBER: 079200131
VISIT DATE: 11/02/2022
NARRATIVE
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LPAs collected the following documents during visit:
· Personnel record (LIC 500)
· C1’s admission agreement
· Needs & Services plan/Progress Notes
· Physician’s report (LIC602A)
· Incident reports
· October 22. 2022 Sign in / Sign out sheets
· Death report (LIC624A)

PD confirmed with LPAs during visit that a death report was not completed or submitted to CCLD within 24 hours of notification by coroner’s office on 10/31/22 that C1 has passed away on 10/27/ in San Mateo county.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/02/2022 12:31 PM - It Cannot Be Edited


Created By: Daisy Panlilio On 11/02/2022 at 11:52 AM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PATHWAY, THE
FACILITY NUMBER: 079200131

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2022
Section Cited
CCR
81061(b)(1)(A)

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Upon the occurrence, during the operation of the facility, of any of the events specified in Section 81061(b)(1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in Section 81061(b)(2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (A) Death of any client from any cause...
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Program Director & Administrator corrected deficiency during visit.

Program Director completed the death report and gave LPAs a copy during visit.
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This requirement was not met as evidenced by staff failing to complete and submit C1's death report within 24 hours of notification which posed an immediate violation of reporting requirements.
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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:Bennett Fong
LICENSING EVALUATOR NAME:Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022


LIC809 (FAS) - (06/04)
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