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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005920
Report Date: 08/26/2021
Date Signed: 08/26/2021 01:23:25 PM

Document Has Been Signed on 08/26/2021 01:23 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ALLIED PATHWAYS CARE HOME LLCFACILITY NUMBER:
306005920
ADMINISTRATOR:LEONARD, KENFACILITY TYPE:
735
ADDRESS:27341 LAS NIEVESTELEPHONE:
(818) 384-9331
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 4CENSUS: 4DATE:
08/26/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:TIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced case management visit to this facility to follow up on the incident reports that Community Care Licensing Division (CCLD) Orange Regional Office received from this facility. Via phone, LPA spoke with Administrators (ADs) Gerald Jones and Kevin Clark. LPA stated the purpose of this visit.

On August 16, 2021 CCLD received a report from the facility indicating what had happened to one of their staff members.

ADs Jones and Clark discussed the event that had happened and what were the steps that the facility is taking to ensure the health and safety of the clients in care.

On August 20, 2021, CCLD received an incident report on Client 1 who was brought to the hospital for further evaluation and management.

ADs discussed the current plans for Client 1.

For this visit, no citation was issued at this time.

LPA Marin conducted a phone exit interview with ADs Gerald Jones and Kevin Clark. Both ADs gave consent for Staff 1 to sign and receive the report. LPA left copy of this report in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
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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