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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208991
Report Date: 07/14/2022
Date Signed: 07/14/2022 01:37:13 PM

Document Has Been Signed on 07/14/2022 01:37 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PATHWAY HOMESFACILITY NUMBER:
157208991
ADMINISTRATOR:JOHNSON, JASONFACILITY TYPE:
740
ADDRESS:2714 GOSFORD RD#DTELEPHONE:
(661) 735-5108
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 6CENSUS: 3DATE:
07/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jason Johnson, Licensee/Administrator
Elizabeth Ramos, Co-Administrator		TIME COMPLETED:
01:50 PM
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On 7/14/22 at 10:45 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - incident inspection. LPA explained reason for inspection and was granted entry. LPA met with Co-Administrator Elizabeth Ramos. Licensee (LIC) Jason Johnson arrived a short time later.

CCL received a Special Incident Report (SIR) for an incident that occurred on 5/18/22. On 5/18/22, staff (S1) discovered the overflow bottle of Acetaminophe/codei 300-30 mg Qty: 90 for R1 that was filled on 5/11/22 was missing as S1 was getting ready to log the start date of the overflow bottle for the next day's administration. LIC conducted an internal investigation and could not substantiate a finding. LIC reported the incident to Bakersfield Police Department.

LPA reviewed records and conducted interviews.

A deficiency is being cited based on LPA's interviews and records review in accordance with the CCR Title 22. See LIC 809D.

Exit interview conducted. A copy of this report and appeal rights were given to Licensee Jason Johnson, whose signature confirms receipt of this report. A Plan of Correction was made with Licensee Jason Johnson.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
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 07/14/2022 01:37 PM - It Cannot Be Edited


Created By: Malia Thao On 07/14/2022 at 01:15 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PATHWAY HOMES
FACILITY NUMBER: 157208991

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2022
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
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Licensee started a new procedure for narcotic medication administration following the incident. Licensee will submit proof of the written procedures for narcotic medication administration to CCL by POC due date.
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LPA found that on 5/18/22, staff (S1) discovered the overflow bottle of Acetaminophe/codei 300-30 mg Qty: 90 for R1 that was filled on 5/11/22 was missing as S1 was getting ready to log the start date of the overflow bottle for the next day's administration, this poses an immediate health or personal rights risk to residents 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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022


LIC809 (FAS) - (06/04)
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