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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209297
Report Date: 06/28/2023
Date Signed: 06/28/2023 04:45:50 PM


Document Has Been Signed on 06/28/2023 04:45 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



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: 24DATE:
06/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jonathan Johnson, Licensee/AdministratorTIME COMPLETED:
05:15 PM
NARRATIVE
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On 6/28/23 at 2:30 PM, Licensing Program Analyst (LPA) Malia Thao conducted a case management - deficiencies inspection. LPA met with Licensee/Administrator (LIC) Jonathan Johnson and Facility Manager (MAN) Nicole Morehead.

During the inspection for complaint #24-AS-20230622113235, LPA found the following deficiencies:

1. R1 returned to the facility from the hospital last week with a new order for use of oxygen gas administration and the facility did not create a written care plan for R1.

2. R1 and R3 do not have health screening records. R3 does not have TB results. R1 has been working since 4/26/23 and R3 has been working since 6/8/23.

3. R2 and R3 do not have proof of initial training. R2 has been working in the facility since 5/19/23 and R3 has been working since 6/8/23.

Deficiencies are being cited based on LPA observations, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted and Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Licensee Jonathan Johnson, whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 06/28/2023 04:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2023
Section Cited
CCR
87611(b)

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87611 General Requirements for Allowable Health Conditions (b) The licensee shall complete and maintain a current, written record of care for each resident that includes, but is not limited to, the following:
This requirement is not met as evidenced by:
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Licensee will submit proof of written care plan for use of oxygen gas administration for R1, to CCL by POC due date.
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R1 returned to the facility from the hospital last week with a new order for use of oxygen gas administration and the facility did not create a written care plan for R1, which poses a potential health, safety, or personal rights risk to residents in care.
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Type B
07/12/2023
Section Cited
CCR87411(f)

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87411 Personnel Requirements – General (f) All personnel,..., 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...

This requirement is not met as evidenced by:
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Licensee will submit proof of R1 and R3's health screening to CCL by POC due date.
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During the inspection for complaint #24-AS-20230622113235, LPA found that R1 and R3 do not have health screening records. R3 does not have TB results. R1 has been working since 4/26/23 and R3 has been working since 6/8/23. This poses a potential health, safety, or personal rights risk to residents 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: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/28/2023 04:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2023
Section Cited
CCR
87411(c)

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87411 Personnel Requirements – General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69:
This requirement is not met as evidenced by:
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Licensee will submit proof of 40-hour initial training for R2 and R3, and proof of 24-hour medication administration for R3, to CCL by POC due date.
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During the inspection for complaint #24-AS-20230622113235, LPA found that R2 and R3 do not have proof of initial training. R2 has been working in the facility since 5/19/23 and R3 has been working since 6/8/23. This poses a potential health, safety, or personal rights risk to residents 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: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
LIC809 (FAS) - (06/04)
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