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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206836
Report Date: 06/27/2022
Date Signed: 07/05/2022 08:48:20 PM

Document Has Been Signed on 07/05/2022 08:48 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PATHWAYS ADLER HOMEFACILITY NUMBER:
107206836
ADMINISTRATOR:JOHNSON, D. MAEFACILITY TYPE:
735
ADDRESS:130 ADLER AVE.TELEPHONE:
(559) 325-3528
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 4CENSUS: 4DATE:
06/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:Direct Support Personnel, Patsy WalshTIME COMPLETED:
02:22 PM
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On 06/27/2022, Licensing Program Analyst, M. Garza arrived at the facility unannounced to conduct the required Infection Control Inspection. LPA contacted House Manager, Shalon Bowie who stated they were unavailable. House Manger gave permission for Direct Support Personnel, Patsy Walsh to complete tour and sign report. LPA was permitted entry into the facility. LPA was not COVID pre-screened upon entry. LPA observed a central entry point with a supply of hand sanitizer, masks and gloves. Documented routine symptom screening for resident's and staff are being completed. The facility does not have a sign in policy for visitors. Residents at Day Program during visit.

Infection Control plan has not been received. LPA toured the facility inside and out. Required postings of signs to include hand washing, coughing etiquette and physical distancing were observed throughout the facility. Staff were all observed wearing face coverings. Facility has designated visitation areas. Covered trash bins in kitchen observed but trash cans in restrooms were not. LPA did not observe a 30 day supply of PPE. Residents have a 30 day supply of medications. Sinks are well stocked and liquid soap for hand washing however, no paper towels for hand drying observed. FIT testing has not been completed for staff.

Through LPA observation of documentation and interview with staff, the required infection control practices are found to be not in compliance. Technical Violation given for infection control practices.

Exit interview completed. A copy of this report was given.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
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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