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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801066
Report Date: 01/20/2023
Date Signed: 01/20/2023 10:42:13 AM

Document Has Been Signed on 01/20/2023 10:42 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: DATE:
01/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Qiuming ZhaiTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 01/20/2023 to conduct a required 1 - year inspection. This inspection is focused on the infection control practices and procedures of this care facility. LPA met with administrator, Qiuming Zhai. Upon arrival nobody was present at the facility. LPA called administrator who arrived shortly. Clients were attending day programs.

LPA toured building and grounds which were clean and in good repair. Exits and walkways were clear from obstructions. COVID postings and screening materials were present at the front entrance. High touch surface areas are disinfected daily. Bathrooms had necessary grab bars and nonslip flooring. Facility has a sufficient amount of perishable and nonperishable food. Sufficient personal protective equipment was available to support a client in isolation. Toxins were locked and secured. Medications were locked and secured. Fire extinguishers were charged and current. Staff have been given infection control training. Staff and clients are fully vaccinated.

LPA is requesting the following documents be submitted to Community Care Licensing within 30 days of today's inspection:

LIC 610 Emergency Disaster Plan
LIC 500 Personnel Report
LIC 9020 Client Roster
LIC 400 Affidavit regarding client cash resources
LIC 402 Surety Bond

Exit interview conducted with administrator and a copy of this report emailed to the facility.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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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