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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 06:58:23 PM

Document Has Been Signed on 11/17/2021 06:58 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:House Manager Diana DiazTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst LPA conducted a Case Management to follow up on issues listed in NCC meeting. 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.

LPA Shawna Doucette and House Manager toured the facility. LPA observed there not to be a two day supply of perishable food and seven day supply of non-perishable food. LPA interviewed staff and residents.

LPA reviewed resident records and staff records. Facility has age exceptions for all residents in care that require an exception.

Deficiencies are being cited based on LPA's observation, interviews conducted, and record review in accordance with the CCR Title 22. See LIC 809D.

An exit interview was conducted with House Manager Diana Diaz and a copy of this report with Plans of Corrections and appeal rights was provided to Licensee Jason Johnson.


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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Document Has Been Signed on 11/17/2021 06:58 PM - It Cannot Be Edited


Created By: Shawna Doucette On 11/17/2021 at 01:36 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: 11/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2021
Section Cited
CCR
87555(b)(26)

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87555 General Food Service Requirements (b) The following food service requirements shall apply:(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
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Plan of Correction POC Licensee agrees to submit a receipt of food containing all food groups by POC due date 11/19/21.
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This requirement was not met: Based on observation and interviews Licensee does not have a minimum of one week nonperishable foods or a minimum of two days of perishable maintained at the facilty which poses a potential Health, Safety or personal rights risk to the clients in care.
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Type B
11/26/2021
Section Cited
CCR80065(g)(2)(A)

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80065 Personnel Requirements(g) All personnel, including the licensee, administrator and volunteers, shall be in good health, and shall be physically, mentally, and occupationally capable of performing assigned tasks.(2) A health screening report signed by the person
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performing such screening shall be made on each person specified above, and shall indicate the following:(A) The person's physical qualifications to perform the duties to be assigned. This requierment was not met evidenced by: Based on review of records S1 and S2 did not have Health Screening signed by a physician which poses a potential Health, Safety or personal rights risk to the clients in care.
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Plan of Correction POC Licensee agrees to submit Health Screening for S1 and S1 by POC due date 11/26/21
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2021


LIC809 (FAS) - (06/04)
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