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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206784
Report Date: 02/15/2022
Date Signed: 02/16/2022 11:21:03 AM

Document Has Been Signed on 02/16/2022 11:21 AM - 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:
02/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:House Manager Diana Diaz and House Manager Liz RamosTIME COMPLETED:
02:30 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 House Manager Diana Diaz and discussed the purpose of the visit. LPA Shawna Doucette, House Manager Diana Diaz and House Manager Liz Ramos began the tour at the front entrance of the facility.

Upon entry LPA observed new flooring in the facility. LPA observed a two day supply of perishable food however did not observe a seven day supply of non-perishable food.

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

Deficiencies are being cited 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: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
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 02/16/2022 11:21 AM - It Cannot Be Edited


Created By: Shawna Doucette On 02/15/2022 at 12:40 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: 02/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
02/16/2022
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 2/16/22.
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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 maintained at the facilty which poses an immediate Health, Safety or personal rights risk to the clients in care.
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Deficiency Dismissed
Type B
02/18/2022
Section Cited
CCR80086(a)

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80086 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change. This requirement was not met: Based on observation Licensee installed new flooring without notifying Licensing 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 a wriiten form stating the understanding of the regulation by POC due date.
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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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022


LIC809 (FAS) - (06/04)
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