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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803615
Report Date: 11/16/2022
Date Signed: 11/16/2022 09:25:27 AM

Document Has Been Signed on 11/16/2022 09:25 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PATHWAYSFACILITY NUMBER:
126803615
ADMINISTRATOR:RANKIN, LEAHFACILITY TYPE:
772
ADDRESS:2370 BUHNE STREETTELEPHONE:
(707) 442-5721
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY: 16CENSUS: 13DATE:
11/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Leah RankinTIME COMPLETED:
09:45 AM
NARRATIVE
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At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to an incident report submitted to CCL on 10/07/2022. LPA met with Administrator Leah Rankin. The incident was in regards to a medication error that occurred on 10/03/2022. While assisting with the administration of medication, S1 provided C1 a smaller dose of medication than ordered by physician. Staff notified the programs nursing consultant and program administrator of the error. Facility will be conducting training for all staff to ensure medication errors do not occur in the future. Facility will also be conducting training for all clients, as the ability to handle their own medication is a goal of this program.


Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Leah Rankin and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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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Document Has Been Signed on 11/16/2022 09:25 AM - It Cannot Be Edited


Created By: Christopher Arnhold On 11/16/2022 at 08:46 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PATHWAYS
FACILITY NUMBER: 126803615

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2022
Section Cited
CCR
81075(b)

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81075 Health-Related Services:(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by: Based on
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Licensee will provide training for all staff to ensure medication errors do not occur in the future. Training will be scheduled by POC date of 11/17/2022 and will be conducted by 12/16/2022. Evidence of
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records reviewed and interview conducted, staff provided C1 another clients medication. This poses an Immediate Health risk to clients in care.
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completed training to be submitted to CCL upon completion of training.

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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:Bethany Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022


LIC809 (FAS) - (06/04)
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