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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107207095
Report Date: 05/19/2022
Date Signed: 05/19/2022 01:39:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/07/2022 and conducted by Evaluator Kamaldeep Kaur
COMPLAINT CONTROL NUMBER: 24-AS-20220207152457
FACILITY NAME:PATHWAYS SELLAND HOMEFACILITY NUMBER:
107207095
ADMINISTRATOR:LUNA, NANCYFACILITY TYPE:
735
ADDRESS:6460 N. SELLAND HOMETELEPHONE:
(559) 269-4366
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 4DATE:
05/19/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Licensee Mae Johnson TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff are not being properly trained
Clients medications are being mishandled while in care
Staff behavior poses as a risk to the clients while in care
INVESTIGATION FINDINGS:
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The Department conducted interviews and checked and reviewed residents’ medication. Medication check confirmed that residents’ medications are not handled properly because centrally stored medications lists were missing for all residents. The licensee also confirmed that staff are not properly trained. The preponderance of evidence standard has been met, therefore, the above allegations are substantiated. Per Title 22, the following deficiencies are being cited on the attached 9099D. Plan of correction discussed. Appeal rights given. Exit interview completed.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda White
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
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 2
Control Number 24-AS-20220207152457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PATHWAYS SELLAND HOME
FACILITY NUMBER: 107207095
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2022
Section Cited
CCR
80075(b)(6)(D)
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80075(b)(6)(D) Health Related Services
For every prescription…there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication…this requirement was not met as evidenced by:
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Administrator agrees to provide a training plan on medications and care and supervision of residents by the due date. The plan will include subject matters and date and times and signatures of staff of intended in serviced trainings
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Based on observation and review of medications, facility was unable to provide a centrally stored prescription medication lists for the residents’ medications, which poses an immediate health and safety risk to the resident in care.
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Type B
06/02/2022
Section Cited
CCR
80065(f)(3)
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80065(f)(3) Personnel Requirements
All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance…This requirement was not met as evidenced by:
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Administrator agrees to provide a training plan on medications and care and supervision of residents by the due date. The plan will include subject matters and date and times and signatures of staff of intended in serviced trainings
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Based on interviews conducted, the licensee confirmed that staff have not received proper training, which poses an immediate health and safety risk to the 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.
SUPERVISORS NAME: Brenda White
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2