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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005920
Report Date: 08/10/2022
Date Signed: 08/10/2022 01:36:56 PM

Document Has Been Signed on 08/10/2022 01:36 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:
08/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:42 PM
MET WITH:TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility. LPA was granted entry after completing the Coronavirus 2019 screening procedure. Via phone, LPA spoke with Administrator (AD) Ken Leonard stated the purpose of the visit.

On August 1, 2022, Community Care Licensing Division (CCLD) Orange Office, received an incident report from the facility describing that on July 30, 2022 Client 1 got out of the facility unattended.

On August 2, 2022, LPA Marin conducted an unannounced case management visit. During the visit, LPA observed four clients in care with two of whom were picked up by respective day programs. LPA toured the interior and exterior portions of the facility, and conducted interviews and file review.

Based on observation, interviews and file review, the following deficiencies were observed:
  • Client 1 got out of the facility unattended or unassisted between 10:00 PM to 8:20 AM.
  • At 10:20 AM and 10:21 AM (August 1, 2022) auditory exit alarms installed on the main door and Client 2 exit door were observed non operational.

For this visit, LPA Marin toured the interior and exterior portions of the facility. LPA observed one staff with no clients on the floor. LPA tested the auditory exit alarms installed in all three exits and they were observed to be operational.

Based on the deficiencies observed, LPA Marin issued citations per Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted a phone exit interview with AD Leonard. LPA discussed the deficiencies observed, citations issued, the appeal rights, and the civil penalty assessment form. AD granted permission for staff to sign and receive the report. LPA left copies of this report, LIC809D (deficiency), cited regulations, appeal rights, and civil penalty assessment form in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2022
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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Document Has Been Signed on 08/10/2022 01:36 PM - It Cannot Be Edited


Created By: Albert Marin On 08/10/2022 at 12:05 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ALLIED PATHWAYS CARE HOME LLC
FACILITY NUMBER: 306005920

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2022
Section Cited
CCR
80065(a)

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80065 Personnel Requirements. Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, . This requirement was not met as evidenced by:
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Licensee will ensure that facility will provide competent staff to provide the services necessary to meet client's needs at all times. Threat reduced. As proof of correction, Facility will provide training to staff on adequate supervision of clients in care. Document will be provided to CCLD on or before 08/24/22.
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Based on observation, file review and interviews, the licensee failed to provide competent facility personnel to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. Facility failed to provide supervision to C1, who exited the facility unattended between 10PM - 8:00AM (7/30/22) This posed immediate threat on safety of client in care.
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LPA provided copy of CCR section cited for full reference.

LPA issued an immediate civil penalty assessment form.


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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:Luz Adams
LICENSING EVALUATOR NAME:Albert Marin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/10/2022 01:36 PM - It Cannot Be Edited


Created By: Albert Marin On 08/10/2022 at 12:50 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ALLIED PATHWAYS CARE HOME LLC
FACILITY NUMBER: 306005920

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2022
Section Cited
CCR
80077.3(a)

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80077.3 Care for Clients Who Lack Hazard Awareness or Impulse Control. If a client requires protective supervision because of running/wandering away...installing ... buzzers, or other auditory devices on exterior doors to alert staff when the door is opened... This requirement was not met as evidenced by:
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Facility installed centralized auditory exit alarms in all three exits. Threat reduced. Facility will ensure that the auditory devices are in good repair and operational at all times. Deficiency corrected on this visit.

LPA provided copy of the CCR section cited for full reference.
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Based on observation, Facility failed to maintain auditory devices in good working order at all times. On 8/1/22, LPA observed auditory devices installed on the main door and Client 2 sliding door were non operational. This posed immediate threat on the safety of the clients in care.
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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:Luz Adams
LICENSING EVALUATOR NAME:Albert Marin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022


LIC809 (FAS) - (06/04)
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