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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801066
Report Date: 12/08/2021
Date Signed: 12/08/2021 01:11:30 PM

Document Has Been Signed on 12/08/2021 01:11 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PACIFIC PATHWAYFACILITY NUMBER:
216801066
ADMINISTRATOR:ZHAI, QIUMINGFACILITY TYPE:
735
ADDRESS:1130 LAS GALLINAS AVETELEPHONE:
(415) 902-8495
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 4DATE:
12/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Licensee, Robert ZhaiTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Pacific Pathway, Inc. for the purpose of conducting a Required-1 year inspection. LPA was met outside by the garage by licensee, Robert Zhai. Licensee granted access into the home.

LPA and Licensee toured the facility at 12:45 PM. The building was clean and well organized. Grounds free of any apparent hazards. All exits unobstructed. Smoke; fire; carbon monoxide current. Hot water tested at 118 F degrees. Disinfectants and medications locked and stored away. Fresh and non-perishable food in adequate supply. No bodies of water on premises. No firearms. Sufficient linens and bedding for the clients. Bathrooms clean and adequately stocked. Medications were stored and inaccessible to clients according to regulations. Disaster drill log current. Fire extinguisher was last charged on July 2021. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the inspection. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. All client’s bedrooms have lighting & appropriate furnishings, and facility has mattress pads available for clients as required by Title 22 Regulations.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE in the office. Facility is in the process of being N95 Fit tested.

No deficiencies were cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the facility licensee, Robert Zhai.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
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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