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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206784
Report Date: 11/17/2021
Date Signed: 11/17/2021 07:00:03 PM

Document Has Been Signed on 11/17/2021 07:00 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:PATHWAY HOMESFACILITY NUMBER:
157206784
ADMINISTRATOR:JOHNSON, JASONFACILITY TYPE:
735
ADDRESS:15923 SAN MARCO PLACETELEPHONE:
(661) 302-4825
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 6CENSUS: 6DATE:
11/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:House Manager Diana DiazTIME COMPLETED:
02:00 PM
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Licensing Program Analyst LPA Shawna Doucette conducted an Annual Infection Inspection on this date. LPA was met by Staff Diana Gamez and discussed the purpose of the visit. House Manager Diana Diaz responded to the facility to assist with the inspection. LPA and House Manager Diana Diaz began the tour at the front entrance/office of the facility.

Facility has a mitigation plan however does not have the LIC 808 plan completed. House Manager will submit plan to LPA via email.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Covid-19 related signs were observed in the common areas. LPA did not observe hand washing signs.

Cleaning supplies were observed behind a locked closet door. LPA observed the following personal protective equipment in a storage cabinet ; gowns, gloves, and masks. LPA did not see any N95 masks. Facility did not have training records for infection control training. LPA observed all facility staff to not be wearing masks upon arrival. Staff put mask once LPA entered the facility.

Resident’s files have updated emergency contact information.

Exit interview was conducted and a copy of this report was provided
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2021
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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