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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002375
Report Date: 05/09/2023
Date Signed: 05/09/2023 02:26:42 PM

Document Has Been Signed on 05/09/2023 02:26 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:HARVIN'S PATHWAY LLCFACILITY NUMBER:
455002375
ADMINISTRATOR:SYBERT, MICHAELFACILITY TYPE:
735
ADDRESS:5773 BISHOP LANETELEPHONE:
(530) 378-2585
CITY:ANDERSONSTATE: CAZIP CODE:
96007
CAPACITY: 4CENSUS: DATE:
05/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Michael Sybert - administratorTIME COMPLETED:
02:30 PM
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05/09/2023 12:45 PM Licensing Program Analysts (LPAs) Rebecca Knight and Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPAs met with administrator Michael Sybert ( Administrator cert. #6044805735 exp 7/20/23 ) and explained the purpose of the visit.

LPAs and the administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. Medications were also reviewed.

Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Medication is locked in a cabinet.

Administrator certificate is current. All employees requiring background checks are cleared. All required postings are displayed within facility.

Pool is fenced, inaccessible, with a secure pool cover. No firearms are on premises. Smoke detectors are all operational. Fire extinguishers are fully charged and were inspected in March 2023. Last disaster drill was conducted in March 2023 which was a major accident drill the facility has been conducting drills every 6 months. In addition the facility conducts monthly fire drills. In the areas toured no immediate health, safety, or personal rights violations were observed.

No deficiencies are being cited as a result of today’s inspection.



Exit interview conducted and copy of report was provided to administrator Michael Sybert.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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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