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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206836
Report Date: 06/27/2022
Date Signed: 06/27/2022 03:56:13 PM

Document Has Been Signed on 06/27/2022 03:56 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Direct Support Personnel, Patsy WalshTIME COMPLETED:
04:09 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 faciilty. LPA was not COVID pre-screened upon entry.

While at the facility to complete an annual inspection the following was observed: 2 of 4 bedrooms have exposed light sockets, 4 of 4 bedrooms observed without lamps, food source not observed to be the required 2 day perishable/7 day non-perishable, left side of back yard fence observed with broken boards and leaning, a fallen tree observed in the back yard.

During visit LPA observed two exit doors that were dead bolted. Staff has access to the locks. LPA will review the file and return to the facility at a later date to address.

Deficiencies issues on LIC 809D. An exit interview was completed. A copy of the report and appeal rights 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)
Page: 1 of 3
Document Has Been Signed on 06/27/2022 03:56 PM - It Cannot Be Edited


Created By: Mary Garza On 06/27/2022 at 02:54 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PATHWAYS ADLER HOME
FACILITY NUMBER: 107206836

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2022
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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Per House Manager the tree will be cleaned up by 6/30/22. Light bulbs will be replaced today 6/27/22 and the fence will be fixed by 6/28/22 by maintenence. Pictures will be provided by POC date. Regulation will be reviewed and a sign in sheet will be provided to CCL.
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This requirement was not met as evidence by: LPA observation of 2 of 4 bedrooms have exposed light sockets, left side of back yard fence observed with broken boards and leaning, a fallen tree observed in the back yard.
This posses a potential health and safety risk to residents in care.
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Type B
07/08/2022
Section Cited
CCR85088

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85088 Fixtures, Furniture, Equipment and Supplies (c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies...(2)Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.
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House Manager stated they will provide lamps in residents rooms by 6/28/22. Pictures will be sent to CCL by POC date. Regulation will be reviewed and a sign in sheet will be provided to CCL.
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This requirement was not met as evidence by: LPA observation that 4 of 4 bedrooms observed without lamps. This posses a potential health and safety 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:See Moua
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/27/2022 03:56 PM - It Cannot Be Edited


Created By: Mary Garza On 06/27/2022 at 03:13 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PATHWAYS ADLER HOME
FACILITY NUMBER: 107206836

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2022
Section Cited
CCR
85076(d)(1)

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85076 Food Service (d) The licensee shall meet the following food supply and storage requirements:(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.
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House Manager stated that they will go grocery shopping and provide receipts to CCL by POC date. Training to be completed with staff on regulation of Food Service. A sign in sheet will be provided and turned in.
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This requirement was not met as evidence by: LPA observation of the food source not being the required 2-day perishable and 7-day non-perishable. This posses a potential health and safety 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:See Moua
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022


LIC809 (FAS) - (06/04)
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