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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200139
Report Date: 01/25/2024
Date Signed: 01/25/2024 12:38:15 PM

Document Has Been Signed on 01/25/2024 12:38 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 TO CHOICES DAY SERVICESFACILITY NUMBER:
079200139
ADMINISTRATOR:JUAN B. VELASQUEZFACILITY TYPE:
775
ADDRESS:751 BELMONT WAYTELEPHONE:
(510) 724-9042
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY: 60CENSUS: 4DATE:
01/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nadia ValdovinosTIME COMPLETED:
01:00 PM
NARRATIVE
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On 1/10/2024 at 9:30am LPAs Carol Fowler and Tonica Syess-Gibson attempted to conduct an unannounced annual random visit. LPAs arrived at the facility and found no one present. LPAs contacted the Program Manager via telephone and obtain hours of operation, Tuesday, Thursday and Friday in person 9:00AM to 12:00PM.

An unannounced 1 year required inspection was conducted by Licensing Program Analysts (LPA) Carol Fowler on 01/25/24 starting at 9:30am. During the visit, LPA met with Program Director, Nadia Valdovinos. LPA inspected the day program inside and out including but not limited to: activity room(s), conference room, storage area, kitchen and bathroom(s).

LPAs observed the entire day program had constant supervision throughout the facility.

The day program was at a comfortable temperature. Hot water temperature was measured at 105.1 degrees Fahrenheit. Day programs do not distribute or handle any medications. No bodies of water. Fire drill was last conducted on 01/12/24 and emergency disaster plan is implemented and dated 1/11/24. Day program is well ventilated with appropriate lighting & bathrooms.

Facility has trained staff that meet the clients' needs.

LPA reviewed staff records and observed that all have criminal record clearances and associated with the facility. Clients’ records were to be organized and filed properly. Day Program does not store or handle clients medication/ does not centrally store medication.

continue on LIC809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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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Document Has Been Signed on 01/25/2024 12:38 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/25/2024 at 11:31 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 TO CHOICES DAY SERVICES
FACILITY NUMBER: 079200139

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having a non-working carbon monoxide detector which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Administrator agreed to purchase a new carbon monoxide detector and submit the receipt to CCL by the POC date.
Type A
Section Cited
CCR
80020(a)
80020 (a) Fire Clearance

(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having 3 expired fire extinguishers which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Administrator agrees to service or purchase new fire extinguishers and discard expired ones and send a picture of new/serviced fire extinguishers with updated tag to CCL by POC date.
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:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024


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 TO CHOICES DAY SERVICES
FACILITY NUMBER: 079200139
VISIT DATE: 01/25/2024
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continue from LIC809

LPA observed the following deficiencies:

· At 10:05am, LPA observed expired fire extinguisher.
· At 10:15am, LPA observed carbon monoxide detector not working.

The following forms to be updated and submitted to CCL by 02/02/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 610D Emergency Disaster Plan


The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (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. A copy of this report and appeal rights provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC809 (FAS) - (06/04)
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