216803455-10-19-2023-21-AS-DTOA-CWRVKU-20231019163053

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803455
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:31:01 PM

Document Has Been Signed on 10/19/2023 04:31 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	PACIFIC PATHWAY, INC.		FACILITY NUMBER:	216803455
ADMINISTRATOR:	ZHAI, QIUMING		FACILITY TYPE:	735
ADDRESS:	1023 LAS GALLINAS AVENUE		TELEPHONE:	(415) 902-8495
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY: 4		CENSUS: 2	DATE:	10/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:07 PM
MET WITH:	Robert "Qiuming" Zhai, Administrator		TIME COMPLETED:	04:45 PM

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	On 10/19/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Administrator, Robert Zhai. The facility currently provides care for 2 clients, both of which were attending day program and arrived later in the visit. LPA continued with a tour of the facility with staff. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 9/14/2023. Smoke and carbon monoxide detectors were found throughout the facility, tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. Water at faucets accessible to clients was measured between 103.8 and 104.5 degrees F which is within Title 22 Regulations. During inspection, LPA observed cabinet in client restroom containing cleaning supplies to be unsecured. Clients were not home at the time observations and lock was secured immediately. Administrator, staff and LPA discussed compliance moving forward. Technical Violation issued. LPA continued with a tour of the backyard and outside parameters and found both emergency exits along the sides of the home to be unobstructed. Two sheds were also located in the backyard for additional storage and found to be secured. Facility conducts and records emergency disaster drills on a quarterly basis. Medications are located in a designated cabinet located in the facility common area and found to be secured. A spot medication count was conducted for clients and found to be in order. LPA conducted a review for staff files and found all staff to have annual training to be completed and on file. Upon review of 1st aid & CPR training, LPA found that 2 out of 3 staff are in need of certification renewal. LPA continued with a reviewed of all client records and found all documents including Golden Gate Regional Center Individual Program Plans and Physician's Reports to be current. LPA found that client's (C1) Individual Program Plan was not on file but contacted Golden Gate Regional Center Case Manager confirming an assessment was completed in September 2023 with pending copy of plan to be sent to the Administrator. Continued onto LIC809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PACIFIC PATHWAY, INC.	FACILITY NUMBER: 216803455
	VISIT DATE: 10/19/2023

NARRATIVE

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All clients attending day program are currently provided transport to and from the facility directly from the day programs. Upon interview and observation, LPA learned that client (C2) had recently been medically treated and recommended for the use of a walker due to slight decline in ambulation. Client is receiving physical therapy for potential transitioning to independent walking but currently utilizes a walker. LPA and Administrator discussed fire clearance requirements and Administrator agreed to request for an updated fire clearance inspection non-ambulatory status. Administrator completed a LIC200 Application Form and updated facility sketch for the fire clearance request. Completed documents were provided to LPA for processing.

Administrator, Robert Zhai's Administrator Certification 6005335735 is currently pending for renewal. LPA confirmed on CCLD Pending Application list that the certification application payment and training was received as of 9/21/2023.

LPA requested the following documents be sent to CCL by COB 11/19/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Proof of ownership

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/19/2023 04:31 PM - It Cannot Be Edited

Created By: Dominic Tobola On 10/19/2023 at 04:00 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PACIFIC PATHWAY, INC.	FACILITY NUMBER: 216803455
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(f)

Health-Related Services

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 3 staff certifications for 1st aid & CPR training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2023
	Plan of Correction
1 2 3 4	Administrator agrees to schedule training and ensure staff S1 & S2 have updated 1st Aid & CPR Certification. Administrator to submit proof of training to CCLD by POC date 10/30/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Kimberley Mota

LICENSING EVALUATOR NAME:

Dominic Tobola

LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

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