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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209297
Report Date: 08/30/2023
Date Signed: 08/31/2023 04:35:09 PM


Document Has Been Signed on 08/31/2023 04:35 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 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: 27DATE:
08/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:41 PM
MET WITH:Nicole Morehead, Facility ManagerTIME COMPLETED:
06:15 PM
NARRATIVE
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On 08/30/23, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a required 10 day inspection. During the course of the investigation, LPA reviewed records and observed residents in care.

LPA toured a sample of resident rooms and observed Resident R1, in bed with full bed rails. LPA observed R1 to bedridden, unable to turn without assistance. R1 is not receiving Hospice Care services and is not temporarily bedridden. A review of R1's discharge papers from the Skilled Nursing Facility (SNF) dated 08/14/23, state R1's ambulatory status is total care and total care for ADL's. Interviews with staff state, R1 is a 2 person assist.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 809-D. An exit interview was conducted with facility manager, as Administrator was unavailable to sign reports.

A copy of this report and appeal rights were discussed and provided at the time of visit. A plan of correction was developed by facility manager and reviewed with LPA. POC due date is 09/22/23.



SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
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 08/31/2023 04:35 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: PATHWAY ASSISTED LIVING/ WESTCHESTER GARDENS
FACILITY NUMBER: 157209297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/21/2023
Section Cited
CCR
87608(B)

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87608 Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
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Facility manager has removed the bed rails. In addition, an appointment has been made with R1's Primary treating physician (PTP) for 09/21/23. Facility manager will provide CCL with an updated LIC602 from PTP appointment. Ambulatory status will specifically be addressed in LIC602. by POC date
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 This requirement was not met as evidenced by LPAs observation of Resident R1's bed with full bed rails. LPA reviewed discharge paperwork from SNF dated 08/14/23, stating R1's ambulatory status is "total" care. R1 is not receiving Hospice Care Services. This poses a potential risk to the health, safety or personal rights to persons in care.
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Type B
09/30/2023
Section Cited
CCR87613(a)(2)(A)

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87613 General Requirements for Restricted Health Conditions
(a) Prior to admission of a resident with a restricted health condition, the licensee shall:(2) Ensure that facility staff who will participate in meeting the resident’s specialized care needs complete training provided by a licensed professional sufficient to meet those needs. (A)Training shall include hands-on instruction in both general procedures and resident-specific procedures.
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Facility manager will contact a skilled professional, who will provide hands on instruction, for all care staff. Training will be completed for each incontinent resident, in both general procedures and resident-specific procedures by POC date.
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This requirement was not met as evidenced by LPA's observation of Resident R1, records review and interviews with staff. Facility has not completed training with a licensed professional for incontinence care. Facility currently has 8 out of 27 residents with incontinence. This poses a potential risk to the health, safety or personal rights to persons 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: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
LIC809 (FAS) - (06/04)
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