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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803455
Report Date: 08/23/2022
Date Signed: 08/24/2022 08:35:50 AM

Document Has Been Signed on 08/24/2022 08:35 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PACIFIC PATHWAY, INC.FACILITY NUMBER:
216803455
ADMINISTRATOR:ZHAI, QIUMINGFACILITY TYPE:
735
ADDRESS:1023 LAS GALLINAS AVENUETELEPHONE:
(415) 902-8495
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 4CENSUS: 3DATE:
08/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Robert (Qiuming) ZhaiTIME COMPLETED:
12:45 PM
NARRATIVE
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At approximately 9:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Administrator, Robert Zhai. The visit is focused on the Infection and Control Practices of this facility.

Upon arrival at the facility, LPA had their temperature checked and logged. LPA conducted a walk-through of the facility and observed the following: Some COVID-19 signs were observed at the entry way and throughout the facility. Hand-washing signs were observed in the bathrooms and at sinks. All staff present were observed to be wearing a mask. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction.

Facility has a cleaning and disinfecting schedule that occurs at least once per day. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for clients. Staff and Clients are screened daily for COVID-19 symptoms.

LPA and Administrator discussed having more COVID-specific signs throughout the facility and implementing a log for monitoring Staff and Client temperatures.

LPA and Administrator discussed N-95 Fit testing, activities, and PPE. Facility has a plan in place if a staffing shortage were to occur.

Fire extinguishers were last serviced September 2021. Smoke and Carbon Monoxide detectors were tested and operational.

Continued on LIC-809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PACIFIC PATHWAY, INC.
FACILITY NUMBER: 216803455
VISIT DATE: 08/23/2022
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Continued from LIC-809

During walk-through, LPA observed the following disinfectants, cleaning solutions, and poisons unlocked and accessible to Clients in Care – Shout Laundry Detergent Spray located in the garage, Lysol disinfectant spray in the kitchen, Lysol disinfectant spray and RAID bug spray in the Administrator’s office. LPA observed Administrator lock all disinfectants, cleaning solutions, and poisons away and ensured that it was inaccessible to Clients in care.

LPA and Administrator discussed the importance of having disinfectants, cleaning solutions, and poisons being inaccessible to Clients in Care.

LPA requested the following documents to update facility file:
  • Administrative Organization (LIC 309)
  • Affidavit Regarding Client/Resident Cash Resources (LIC 400)
  • Emergency Disaster Plan (LIC 610D)
  • Designation of Facility Responsibility (LIC 308)
  • Personnel Report (LIC 500)
  • Surety Bond (LIC 402)
  • Register of Clients (LIC 9020)
  • Current Administrator Certificate

Documents to be submitted to Community Care Licensing (CCL) by Friday, September 30, 2022

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Plan of Corrections reviewed and developed with Administrator. Copy of report, LIC
9099-D, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/24/2022 08:35 AM - It Cannot Be Edited


Created By: Caitlynn Felias On 08/23/2022 at 11:23 AM
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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PACIFIC PATHWAY, INC.
FACILITY NUMBER: 216803455

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087 Buildings and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, Licensee did not ensure disinfectants and poisons were stored locked and inaccessible to Clients. LPA observed Shout Laundry Detergent Spray located in garage, Lysol disinfectant spray in kitchen, Lysol disinfectant spray and RAID bug spray in Administrator’s office. This poses an immediate health and safety risk to Clients in Care.
POC Due Date: 08/24/2022
Plan of Correction
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LPA observed Licensee lock disinfectants and poison sprays during inspection. Licensee to submit a statement that they understand the requirement and will be in future compliance with the regulation by POC due date Wednesday, 08/24/2022, to Community Care Licensing.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kimberley Mota
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022


LIC809 (FAS) - (06/04)
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