157206784-10-4-2023-24-AS-AWAN-CWATH5-20231004144409

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157206784
Report Date: 10/04/2023
Date Signed: 10/04/2023 02:44:19 PM

Document Has Been Signed on 10/04/2023 02:44 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 HOMES		FACILITY NUMBER:	157206784
ADMINISTRATOR:	JOHNSON, JASON		FACILITY TYPE:	735
ADDRESS:	15923 SAN MARCO PLACE		TELEPHONE:	(661) 302-4825
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93314
CAPACITY: 6		CENSUS: 6	DATE:	10/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:31 AM
MET WITH:	Assistant Administrator, Diana Diaz		TIME COMPLETED:	03:02 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/04/2023, 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. Facility staff informed LPA that Administrator, Jason Johnson is not present in the facility. Staff contacted Assistant Administrator, Diana Diaz, who agreed to meet with LPA. LPA attempted to contact Administrator, Jason Johnson, to inform Administrator of the visit via telephone. Administrator did not answer and LPA was unable to leave a voicemail. LPA met with Assistant Administrator, Diana Diaz LPA reviewed resident and staff records. LPA attempted to review medications, however the facility utilizes an electronic MAR and the system was down for maintenance during today's inspection. LPA is requesting the following: the complete MAR for the months of July 2023 - September 2023 for all residents in care, prescription for bed rails on R1, and the current Individual Service Plan (ISP) for all clients in care, to the Fresno CCL office by noon on 10/05/2023. LPA will return at a later date to review medication records. LPA conducted a tour of the facility with Assistant Administrator. During the inspection the facility appeared clean and odor free and at a comfortable temperature. Common areas were furnished and had adequate seating and lighting available. LPA observed a blind in the window in the dining area to be missing. LPA observed 13 blinds were missing on the sliding glass door near the kitchen in need of repair. Resident bedrooms appeared clean and had required furnishings and adequate lighting. LPA observed the door knob to bedroom 4 was missing. LPA observed residents R1 and R4 to be residing in rooms not listed on the facility sketch, due to conflicting information, LPA will conduct a second file review of the facility file and return at a later date to issue a deficiency if needed. Residents bathrooms appeared clean, water temperature measured at 111.3 degrees F. LPA observed the toilet seat and mirrored cabinet in bathroom 3 to be in need of repair. Facility kitchen appeared to be clean and safe for food preparation. LPA observed 2-day supply of perishable foods and a 7-day supply of non-perishable food. CONTINUED TO 809C

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PATHWAY HOMES	FACILITY NUMBER: 157206784
	VISIT DATE: 10/04/2023

NARRATIVE

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Exterior tour conducted, all exits open and free of obstructions on today’s visit. LPA observed the window screen to the sliding door in kitchen to be in need of repair and the window screen to bedroom 2 was missing. Fire extinguisher is current with a service date of 07/09/2023 . Smoke detectors and carbon monoxide detector observed to operational. Last fire drill conducted on 09/20/2023.

A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.

Exit interview conducted and a plan of correction was reviewed and developed with Assistant Administrator. A copy of this report and appeal rights were discussed and provided to Assistant Administrator, Diana Diaz, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/04/2023 02:44 PM - It Cannot Be Edited

Created By: Alexandria Walton On 10/04/2023 at 02:15 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: 10/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above when the following items were in need of repair: Window screens, toilet seat and mirrored cabinet in bathroom 3, blinds, and the door knob to bedroom 4,which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/06/2023
	Plan of Correction
1 2 3 4	Licensee agrees to repair the items listed above and submit proof that the items have been repaired to the Fresno CCL office by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 10/04/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

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