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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209297
Report Date: 09/25/2023
Date Signed: 12/20/2023 09:08:50 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/13/2023 and conducted by Evaluator Malia Thao
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230613143211
FACILITY NAME:PATHWAY ASSISTED LIVING/ WESTCHESTER GARDENSFACILITY NUMBER:
157209297
ADMINISTRATOR:JOHNSON, JONATHANFACILITY TYPE:
740
ADDRESS:2228 TRUXTUN AVETELEPHONE:
(661) 324-3091
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93301
CAPACITY:36CENSUS: 26DATE:
09/25/2023
UNANNOUNCEDTIME BEGAN:
10:46 AM
MET WITH:Administrator, Nicole MoreheadTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Staff not treating resident with respect
Staff made inappropriate comments towards resident
INVESTIGATION FINDINGS:
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2
3
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5
6
7
8
9
10
11
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13
This is an amended report. On 12/20/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings. LPA met with Administrator, Nicole Morehead.

The Department investigated the allegations of staff not treating resident with respect and staff making inappropriate comments towards a resident and based on interviews and records review, the allegations are substantiated. One deficiency is cited on the attached 9099D. Appeal rights provided and exit interview conducted.

A copy of this report was discussed and provided to Administrator, Nicole Morehead, whose signature on this form confirms receipt of this document.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/13/2023 and conducted by Evaluator Malia Thao
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230613143211

FACILITY NAME:PATHWAY ASSISTED LIVING/ WESTCHESTER GARDENSFACILITY NUMBER:
157209297
ADMINISTRATOR:JOHNSON, JONATHANFACILITY TYPE:
740
ADDRESS:2228 TRUXTUN AVETELEPHONE:
(661) 324-3091
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93301
CAPACITY:36CENSUS: 26DATE:
09/25/2023
UNANNOUNCEDTIME BEGAN:
10:46 AM
MET WITH:Administrator, Nicole MoreheadTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff inappropriately touched resident
Staff forced resident to shower
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This is an amended report. On 12/20/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings. LPA met with Administrator, Nicole Morehead.

The Department investigated the allegations that staff inappropriately touched resident and staff forced resident to shower and based on interviews and records review, there is not a preponderance of evidence to prove or disprove the allegations occurred therefore the allegations are unsubstantiated. No deficiencies cited.

Exit interview conducted. A copy of this report was given to Administrator, Nicole Morehead, whose signature confirms receipt of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 24-AS-20230613143211
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PATHWAY ASSISTED LIVING/ WESTCHESTER GARDENS
FACILITY NUMBER: 157209297
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
09/26/2023
Section Cited
CCR
87468.1(a)(3)
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7
87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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Licensee will submit a written plan to include reaching out to Ombudsmen for training on resident personal rights, to include date of when in-service training for all staff including Licensee and Administrator will be scheduled and completed, and to include submission of in-service training to CCL immediately after completion, to CCL by POC due date.
8
9
10
11
12
13
14
This requirement was not met when S1 flicked the genitals of R1 and S1 and S2 laughed about it. This poses an immediate health, safety and/or personal rights risk to residents in care.
8
9
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14
Request Denied
Type B
09/26/2023
Section Cited
CCR
87468.1(a)(1)
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7
Amended 87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Licensee will submit a written plan to include reaching out to Ombudsmen for training on resident personal rights, to include date of when in-service training for all staff including Licensee and Administrator will be scheduled and completed, and to include submission of in-service training to CCL immediately after completion, to CCL by POC due date.
8
9
10
11
12
13
14
This requirement was not met when S1 called R1 “Old man” and made statements to R1 “You’re my big baby” and You’re my love”. This poses an immediate health, safety and/or personal rights risk to residents in care.
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This deficiency has been amended to amend the deficiency type from a type A to a type B.
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 HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3