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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606198
Report Date: 12/09/2022
Date Signed: 12/09/2022 03:09:52 PM

Document Has Been Signed on 12/09/2022 03:09 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PATHPOINTFACILITY NUMBER:
197606198
ADMINISTRATOR:KIM WHITAKERFACILITY TYPE:
775
ADDRESS:1463 E LOS ANGELES AVETELEPHONE:
(805) 520-8744
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 45CENSUS: 38DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Destiny NadeauTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 12:05 p.m. The LPA met with Destiny Nadeau and explained the reason for the visit.

There are sixteen (16) consumers and four (4) program staff present today. The program currently operates from 9:00 a.m. to 3:00 p.m. The day program was staffed with 1:4 staff to consumer ratios. Temperatures of staff and consumers are taken upon entry into the facility.

Common Activity Space: The facility is a two-story structure with activity rooms, a conference room, two (2) bathrooms, offices, and a food service area. The second floor includes administrative offices and conference rooms. The LPA did not observe any obstructions or hazards. Fire extinguishers were charged and serviced 2/2022. Systems are checked bi-annually. Activities: Activities are designed for individual and as a group. The LPA observed staff working with consumers. Food Service: The kitchen area was clean and in good condition. Consumers bring their meals and the facility can provide emergency meals and snacks. Restrooms: Restrooms were clean and sanitary. At 2:40 p.m., water temperature measured at 109 F.

Files: At 2:30 p.m., the LPA checked staff associations and identified that one staff (Staff #1) had fingerprint clearance but was not associated to this location.

Infection Control: There was a central entry point for symptom screening and temperature checks. The LPA was appropriately screened upon entry. Staff and consumers were wearing appropriate face coverings. Infection Control signs were observed on the front door and throughout the facility. Facility has a sufficient supply of PPE. The facility’s cleaning protocol was sufficient. The facility keeps record of staff and consumer vaccinations. The facility's procedures as it pertains to infection control are adequate.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalties assessed. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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 12/09/2022 03:09 PM - It Cannot Be Edited


Created By: Ashley Smith On 12/09/2022 at 03:02 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PATHPOINT
FACILITY NUMBER: 197606198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82019(e)(2)
Criminal Record Clearance
(e) Prior to working, residing or volunteering in a licensed day program, all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall do the following: (2) Request the licensee or applicant for a license to request a transfer of a criminal record clearance as specified in Section 82019(f); or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, as Staff #1 (S1) was not associated to this location, which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/09/2022
Plan of Correction
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The Program Director agreed to do the following:
1. Ensure S1 is associated to this location prior to allowing S1 to return to the work site.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022


LIC809 (FAS) - (06/04)
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