<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209297
Report Date: 06/28/2023
Date Signed: 06/28/2023 04:44:18 PM

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
06/22/2023 and conducted by Evaluator Malia Thao
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230622113235
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
UNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Nicole Morehead, Facility ManagerTIME COMPLETED:
05:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee does not ensure staff administering oxygen to residents are appropriately trained.
Staff do not safeguard resident's personal belongings.
Staff do not ensure facility is free from roaches.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6/28/23 at 9:54 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an initial 10-day complaint inspection. LPA explained reason for inspection and was granted entry. LPA met with Licensee/Administrator (LIC) Jonathan Johnson and Facility Manager (MAN) Nicole Morehead.

LPA made observations, conducted interviews, and reviewed records. Based on observations, interviews, and record review, LPA found that the Licensee did not ensure staff administering oxygen to residents are appropriately trained, staff did not safeguard resident's personal belongings, and staff did not ensure facility is free from roaches. When R1 was discharged from the hospital last week with orders for oxygen administration, S1 and S2 assisted R1 with oxygen administration even though S1 and S2 were not appropriately skilled professionals, and were not given any specific instructions for how to care for R1 with the use of oxygen gas administration. S1, S2, and MAN stated resident's laundry are collected and laundered together, and may not always know which resident the clothing belongs to. *Continue on LIC9099-C.*
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
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
06/22/2023 and conducted by Evaluator Malia Thao
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230622113235

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
UNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Nicole Morehead, Facility ManagerTIME COMPLETED:
05:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee does not maintain sufficient food service personnel to meet the needs of residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6/28/23 at 9:54 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an initial 10-day complaint inspection. LPA explained reason for inspection and was granted entry. LPA met with Licensee/Administrator (LIC) Jonathan Johnson and Facility Manager (MAN) Nicole Morehead.

LPA made observations, conducted interviews, and reviewed records. LPA found that although the cooks leave work before dinner is served, caregivers are able to serve the residents the dinner that the cooks prepared. The above allegation is unfounded. The allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted. A copy of this report was given to Licensee Jonathan Johnson, whose signature confirms receipt of this report.
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 24-AS-20230622113235
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
VISIT DATE: 06/28/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
*Continued from LIC9099.)

R4 stated R4's clothing have gone missing after being laundered and have not been given back. R4 advised R4 inquired missing clothing to staff but staff did not know and told R4 they had not seen it. S1, S2, and MAN stated staff will and have used disposable underwear from another resident's supply if the resident being changed has run out of their own disposable underwear supply. LPA observed cockroach nymphs scatter after pulling away plastic crate stored under commercial stainless kitchen sink and observed cockroach droppings covering entire floor where crate was stored. Therefore the above allegations are substantiated.

Deficiencies are being cited based on LPA observations, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC9099D.

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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20230622113235
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: 06/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/29/2023
Section Cited
CCR
87618(a)(2)
1
2
3
4
5
6
7
87618 Oxygen Administration - Gas and Liquid (a) ...the licensee shall be permitted to accept or retain a resident who requires the use of oxygen gas administration under the following circumstances: (2) If intermittent oxygen administration is performed by an appropriately skilled professional.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will submit proof of a written plan for what the facility will be doing to ensure oxygen administration is performed by an appropriately skilled professional, or otherwise, to CCL by POC due date.
8
9
10
11
12
13
14
When R1 was discharged from the hospital last week with orders for oxygen administration, S1 and S2 assisted R1 with oxygen administration even though S1 and S2 were not appropriately skilled professionals, and were not given any specific instructions for how to care for R1 with the use of oxygen gas administration. This poses an immediate health, safety, or personal rights risk to residents in care.
8
9
10
11
12
13
14
Type B
07/12/2023
Section Cited
CCR
87217(b)
1
2
3
4
5
6
7
87217 Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents' … personal property and valuables which have been entrusted to the licensee or facility staff…
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will submit proof of written resident laundry procedures and in-service training to all staff, and proof of written plan to address replenishing disposable underwear supply for residents prior to running out, to CCL by POC due date.
8
9
10
11
12
13
14
S1, S2, and MAN stated resident's laundry are collected and laundered together, and may not always know which resident the clothing belongs to. R4 stated R4's clothing have gone missing after being laundered and have not been given back. R4 advised R4 inquired missing clothing to staff but staff did not know and told R4 they had not seen it. S1, S2, and MAN stated staff will and have used disposable underwear from another resident's supply if the resident being changed has run out of their own disposable underwear supply. This poses a potential health or personal rights risk to residents in care.
8
9
10
11
12
13
14
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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20230622113235
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: 06/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2023
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will submit a written plan to show what steps will be taken to address the cockroach infestation, to include how often kitchen will be deep cleaned and how often pest control will conduct treatments, to CCL by POC due date.
8
9
10
11
12
13
14
LPA observed cockroach nymphs scatter after pulling away plastic crate stored under commercial stainless kitchen sink and observed cockroach droppings covering entire floor where crate was stored. This poses a potential health or personal rights risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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
LIC9099 (FAS) - (06/04)
Page: 5 of 5