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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208994
Report Date: 11/29/2021
Date Signed: 11/30/2021 02:17:42 PM

Document Has Been Signed on 11/30/2021 02:17 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:
157208994
ADMINISTRATOR:JOHNSON, JASONFACILITY TYPE:
740
ADDRESS:2714 GOSFORD RD #CTELEPHONE:
(661) 302-4728
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 6CENSUS: 5DATE:
11/29/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:House Manager Elizabeth RamosTIME COMPLETED:
04:15 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 Lupe Garcia and discussed the purpose of the visit. LPA and House Manager Elizabeth Ramos began the tour at the front entrance 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 reviewed resident records and staff records.

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

An exit interview was conducted with House Manager Elizabeth Ramos 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: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2021
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 11/30/2021 02:17 PM - It Cannot Be Edited


Created By: Shawna Doucette On 11/29/2021 at 01:37 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: 157208994

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2021
Section Cited
CCR
87616(a)

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87616 Exceptions for Health Conditions (a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.
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Plan of Correction POC Licensee agrees to submit restrictive health care plan for an exception for R1 to Licensing by POC due date 12/10/21
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This requirement was not met as evidenced by Licensee not having a written exception for a restrictive health care conditon for R1. Based on records review Licensee did not have a written exception for R1's restricitive health care condition which poses an immediate Health, Safety or personal rights risk to the clients in care.
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Type B
12/03/2021
Section Cited
CCR87555(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 12/3/21.
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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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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: 11/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/30/2021 02:17 PM - It Cannot Be Edited


Created By: Shawna Doucette On 11/29/2021 at 02:09 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: 157208994

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/31/2021
Section Cited
CCR
87411(f)

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87411(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
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Plan of Correction POC Licensee agrees to submit Health Screening which show TB results by POC due date 12/31/21
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This requirement was not met evidenced by Based on records review Licensee not having a record of S1's tuberculosis results which poses a potential Health, Safety or personal rights risk to the clients in care.
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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: 11/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2021


LIC809 (FAS) - (06/04)
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