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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206784
Report Date: 10/26/2023
Date Signed: 10/26/2023 01:47:12 PM

Document Has Been Signed on 10/26/2023 01:47 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:
10/26/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:19 AM
MET WITH:Assistant Administrator, Diana DiazTIME COMPLETED:
02:05 PM
NARRATIVE
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On 10/26/2023, Licensing Program Analyst (LPA) arrived unannounced to conduct an annual continuation inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA was granted entry to the facility and facility staff contacted Assistant Administrator, Diana Diaz. LPA met with Assistant Administrator, Diana Diaz.

During today's visit, LPA reviewed medications and conducted a facility tour. Upon review of medications, LPA observed the following: From 07/16/23 – 07/20/23, R1 did not receive the prescribed medication, Quetiapine Fumarat 300MG records indicated that there were "none to give". On 07/07/23, R2 was out of Namzaric 14-10M, and from 08/26/23 – 08/27/2023 R2 was out of Miratazapine. On 07/08/2023, R3 was out of Vitamin D3 and on 08/31/2023, R3 was out of Divalproex. On 07/11/2023, R5 was out of the medication Levetiracetam. There were multiple dates in July 2023 and August 2023, when R6 was out of Mirtazapine. From 08/20/2023 through 08/21/2023, R6 was out of Oxybutynin.

During the period 07/01/2023 through 08/31/2023, there were multiple incidents of residents refusing medications, however the Licensee did not furnish a report to notify Fresno CCLD of the resident's refusal.

During the facility tour, LPA observed that the Licensee did not maintain the original fire clearance that was approved by the fire department, when a room cleared for use as a living room, based on the original facility sketch on record, was being utilized as a resident bedroom. Administrator, Jason Johnson was contacted via telephone, Administrator confirmed that "some modifications" had been done to add a door to the room identified as a living room and a portable closet was placed in the room to satisfy CCLD requirements.

Deficiencies are being issued in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. An immediate civil penalty in the amount of $500 is being assessed for issues related to fire clearance.
Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report, civil penalty, and appeal rights were discussed and provided to Assistant Administrator, Diana Diaz, whose signature on this form confirms receipt of these documents.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2023
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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Document Has Been Signed on 10/26/2023 01:47 PM - It Cannot Be Edited


Created By: Alexandria Walton On 10/26/2023 at 01:08 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: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
80020 Fire Clearance

(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,and record review, the licensee did not comply with the section cited above when the facilty utilized a room that was orignally cleared as a living room as resident bedroom, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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Licensee agrees to submit the LIC200, LIC9054, LIC999 and LIC610D to the Fresno CCL office by the POC due date or relocate R1 to a room that has been approved as a resident bedroom by the fire department, by the POC due date.
Type A
Section Cited
CCR
80075(b)
80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in when residents missed medications on multiple dates during July 2023 and August 2023 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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The Licensee agrees to submit a written statement detialing the steps the facility will take to ensure the requirements for section 80075 are met to the Fresno CCL office by the POC due date.
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: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/26/2023 01:47 PM - It Cannot Be Edited


Created By: Alexandria Walton On 10/26/2023 at 01:21 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: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80061(a)
80061 Reporting Requirements

(a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when on multiple dates during the period of 07/01/2023 through 08/31/2023, residents refused medications and the Licensee did not furnish a report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
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Licensee agrees to train facility staff on the requirements for section 80061 and submit a copy of the training topics and attendance 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: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023


LIC809 (FAS) - (06/04)
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