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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803455
Report Date: 10/29/2024
Date Signed: 10/29/2024 11:27:22 AM

Document Has Been Signed on 10/29/2024 11:27 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 PATHWAY, INC.FACILITY NUMBER:
216803455
ADMINISTRATOR/
DIRECTOR:
ZHAI, QIUMINGFACILITY TYPE:
735
ADDRESS:1023 LAS GALLINAS AVENUETELEPHONE:
(415) 902-8495
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 4CENSUS: 2DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Staff Member, Shelley Li, and Administrator/Licensee, Robert ZhaiTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Yibing (Shelley) Li. Administrator/Licensee, Qiuming (Robert) Zhai, arrived during visit at approximately 9:30AM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance for 3 Ambulatory clients and 1 Non-Ambulatory client for a total capacity of 4 clients. Upon arrival, LPA was informed that there were 2 clients in care with one client out of the facility attending Day Program. LPA was also informed that there was two staff members on-site.

At approximately 9:20AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 9:35AM, LPA conducted a walk-though of the facility with Administrator/Licensee. LPA 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 single story building with 2 Client bedrooms, 2 bathrooms, a staff room, an office room, and common areas. 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. 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 sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.

At approximately 10:00AM, LPA 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 and CPR certification. P&I monies were documented, secure and not commingled. During medication review, LPA observed that the facility uses a written Medication Authorization Record (MAR) and a centrally stored log. LPA observed that some medications were not documented on the log as required. Review of facility's log indicated that facility understands how to document medications appropriately. LPA and Administrator/Licensee discussed reviewing how to correctly log medications when they arrive to the facility (see technical violation, LIC9102, regulation 80075(k)(7).

Continued on LIC809C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PACIFIC PATHWAY, INC.
FACILITY NUMBER: 216803455
VISIT DATE: 10/29/2024
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Continued from LIC809

Administrator's Certificate for Qiuming Zhai (7001408735) was current with an expiration date of 11/20/2025.

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 October 2024.



LPA 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 11/29/2024.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC9102 (Technical Violation/Advisories) discussed and provided to Administrator/Licensee. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
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