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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206784
Report Date: 05/05/2022
Date Signed: 05/05/2022 11:18:38 AM

Document Has Been Signed on 05/05/2022 11:18 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:
05/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Licensee Jason Johnson and House Manager Diana DiazTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst LPA conducted a Case Management to follow up on an incident report. LPA was met by Staff Diana Diaz and discussed the purpose of the visit. Licensee Jason Johnson responded to the facility to assist with the case management.

LPA reviewed records showing that R1 did not receive medication for 3 days due to medication going missing from facility. Facility filed a police report regarding the missing medication and conducted an internal investigation.

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 Licensee Jason Johnson 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: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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 05/05/2022 11:18 AM - It Cannot Be Edited


Created By: Shawna Doucette On 05/05/2022 at 10:08 AM
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: 05/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
05/06/2022
Section Cited
CCR
87465(4)

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87465 Incidental Medical and Dental Care (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and record review of MARS, Licensee did not give R1's PM medications on 5/1/22, R1's AM and PM medications on 5/2/22 and R1's AM medication 5/3/22 which poses an immediate Health, Safety or personal rights risk to the clients in care.
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Plan of Correction POC Licensee agrees submit plan on how to meet 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: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022


LIC809 (FAS) - (06/04)
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