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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801066
Report Date: 02/14/2025
Date Signed: 02/14/2025 11:57:53 AM

Document Has Been Signed on 02/14/2025 11:57 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PACIFIC PATHWAYFACILITY NUMBER:
216801066
ADMINISTRATOR/
DIRECTOR:		ZHAI, QIUMINGFACILITY TYPE:
735
ADDRESS:1130 LAS GALLINAS AVETELEPHONE:
(415) 902-8495
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 4DATE:
02/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee/Administrator Robert ZhaiTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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At approximately 9:00AM, Licensing Program Analyst (LPAs) Deniz and Felias arrived unannounced to conduct a Required 1 Year visit and met with Licensee/Administrator, Robert Zhai. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance and capacity for 6 Ambulatory Clients. Upon arrival, LPAs was informed that there were 4 clients in care with all four clients out of the facility.

LPAs reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPAs conducted a walk-though of the facility with Administrator. LPAs observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a two story building with 4 Client bedrooms, 2 bathrooms, and common areas. The second floor of the house goes into the garage that clients do not have access to. Per conversation with Administrator, in the event of evacuation, clients leave from exits located on the main floor. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. During walkthrough, LPAs observed that some food located in facility fridge and freezer was not labelled or dated appropriately (technical violation issued). There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for client use. Toxins were observed to be stored inaccessible to clients. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for all facility sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit.

LPAs reviewed staff files, client files, client medication, and client P&I monies. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid certification. Medication was observed to be centrally stored and secure. P&I monies were documented, secure and not commingled. Administrator's Certificate for Qiuming Zhai (6005335735) was current with an expiration date on 11/20/2025.

Continued on LIC809C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PACIFIC PATHWAY
FACILITY NUMBER: 216801066
VISIT DATE: 02/14/2025
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Continued from LIC809

Fire extinguishers were last inspected September 2024. Smoke detectors and carbon monoxide detectors were tested and operational. The last facility emergency/disaster drill was conducted on January 9, 2025.

LPAs requested the following documents to update facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate when available

Documents to be submitted to Community Care Licensing (CCL) by due date of 03/14/2025.

Exit interview conducted. Copy of report and LIC9102, discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025
LIC809 (FAS) - (06/04)
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