<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005232
Report Date: 06/29/2023
Date Signed: 06/29/2023 12:59:07 PM

Document Has Been Signed on 06/29/2023 12:59 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PATHWAYS TO SUCCESS FOR SENIORSFACILITY NUMBER:
347005232
ADMINISTRATOR:BERGMAN, DOUGLASFACILITY TYPE:
775
ADDRESS:4640 ORANGE GROVE AVE F4-K1-K2TELEPHONE:
(916) 548-3198
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY: 30CENSUS: 18DATE:
06/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Melissa Jones, Program ManagerTIME COMPLETED:
01:10 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
LPA Hiratsuka, conducted this unannounced annual visit. This program shares a campus with two other day programs operated by the same Licensee. This campus also houses several other programs. LPA conducted all three annuals at the same time. The three facilities are: EMPOWERING OPPORTUNITIES FOR SUCCESS 347005231; PATHWAYS TO SUCCESS FOR SENIORS 347005232; and SAN JUAN ADULT GROWTH EXPERIENCE 347005230.

LPA toured all the rooms the three programs occupy. There are multiple common bathrooms on the campus. This program also has a changing room and quiet area for clients. The main office is in A Wing of the campus. LPA did not observe any health and safety risks to clients. Each program has locked cabinets for storage.

Two client and two staff files for each program were reviewed.

Multiple topics were discussed.


No deficiencies cited.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2023
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 1