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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206784
Report Date: 11/15/2022
Date Signed: 11/15/2022 02:47:37 PM

Document Has Been Signed on 11/15/2022 02:47 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:
11/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:Facility Manager, Elizabeth Ramos and Staff, Cindy LopezTIME COMPLETED:
03:01 PM
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On 11/15/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Administrator, Jason Johnson (AD) was not available during this inspection. LPA received verbal permission from AD to meet with Facility Manager, Elizabeth Ramos and Staff, Cindy Lopez. Upon entry to the facility, LPA observed staff to not be wearing facial coverings. Staff put on a mask once LPA entered the facility. Facility has one central entry and exit. A visitor log / temperature check was observed upon entry.

Facility tour conducted. LPA did not observe signs promoting hand-washing, social distancing, and cough/sneeze etiquette throughout the facility. LPA toured the facility kitchen. Food supply checked. LPA observed an adequate food supply. LPA observed an adequate supply of PPE and cleaning supplies.

Resident bedrooms checked. Beds observed to be at least 6 feet apart. Liquid soap and paper towels are available in the bathrooms. Hand-washing signs observed in resident bathrooms. LPA checked residents' medication and observed a 30 day supply. LPA observed the medication cabinet to be unlocked and accessible to persons other than employees. Resident and staff temperature checks are documented daily. Residents files were reviewed for updated emergency contact information.

LPA is requesting the following documents be submitted to the Fresno CCL office by 11/29/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. Exit interview conducted. A copy of this report and appeal rights were discussed and provided to FM whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2022
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 11/15/2022 02:47 PM - It Cannot Be Edited


Created By: Alexandria Walton On 11/15/2022 at 02:35 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: PATHWAY HOMES
FACILITY NUMBER: 157206784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when the medication cabinet was unlocked and accessible to persons other than employees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2022
Plan of Correction
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for the above section are met to the Fresno CCL office by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022


LIC809 (FAS) - (06/04)
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