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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209133
Report Date: 08/29/2022
Date Signed: 08/30/2022 10:24:48 AM

Document Has Been Signed on 08/30/2022 10:24 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PATHWAY HOMESFACILITY NUMBER:
157209133
ADMINISTRATOR:JOHNSON, JASONFACILITY TYPE:
740
ADDRESS:2717 GOSFORD RD #ATELEPHONE:
(661) 972-6235
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 6CENSUS: 3DATE:
08/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jason Johnson, Licensee/Administrator
Elizabeth Ramos, House Manager		TIME COMPLETED:
01:30 PM
NARRATIVE
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On 8/29/22 at 9:00 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry. House Manager Elizabeth Ramos arrived a short time later and Licensee/Administrator Jason Johnson arrived towards the end of the inspection. Two residents and one staff was present during the inspection.

LPA conducted tour with staff and did not observe any obstructions. No fire issues observed. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and residents do not share bedrooms. LPA checked residents’ medications. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Resident files have updated emergency contact information. Administrator certificate is valid.

The following deficiencies were observed:
1. S1 does not have fingerprint transfer clearance and has been working in the facility since 6/7/22.
2. One bottle of cleaner observed accessible in cabinet under hall bathroom sink, and storage cabinet in garage where all cleaners and chemicals are stored was observed unlocked and accessible.
3. S1 did not have a health assessment completed and has been working since 6/7/22.
4. LPA observed master bathroom shower did not have a non-skid mat or strips available.
5. Upon LPA entry, S1 was only staff on duty and stepped out of the front door to guide LPA to office next door, leaving two residents unsupervised.


Continue on LIC809-C.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2022
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 08/30/2022 10:24 AM - It Cannot Be Edited


Created By: Malia Thao On 08/29/2022 at 11:30 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PATHWAY HOMES
FACILITY NUMBER: 157209133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. S1 does not have fingerprint transfer clearance and has been working in the facility since 6/7/22, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2022
Plan of Correction
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Licensee completed the fingerprint clearance transfer on Guardian website for S1. POC cleared during the inspection.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. One bottle of cleaner observed accessible in cabinet under hall bathroom sink, and storage cabinet in garage where all cleaners and chemicals are stored was observed unlocked and accessible. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2022
Plan of Correction
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Licensee immediately removed the bottle of cleaner to the storage cabinet in the garage and locked the storage cabinet. POC cleared during inspection.
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: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/30/2022 10:24 AM - It Cannot Be Edited


Created By: Malia Thao On 08/29/2022 at 11:30 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PATHWAY HOMES
FACILITY NUMBER: 157209133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. S1 did not have a health assessment completed and has been working since 6/7/22, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2022
Plan of Correction
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Licensee will submit proof of completed health assessment for S1 to CCL by POC due date.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/30/2022 10:24 AM - It Cannot Be Edited


Created By: Malia Thao On 08/29/2022 at 11:37 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PATHWAY HOMES
FACILITY NUMBER: 157209133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
87303 Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:
(5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed master bathroom shower did not have a non-skid mat or strips available, which poses a potential safety or personal rights risk to persons in care.
POC Due Date: 09/06/2022
Plan of Correction
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Licensee will submit proof of non-skid mat in master bathroom shower to CCL by POC due date.
Type B
Section Cited
CCR
87411(d)(3)
87411 Personnel Requirements – General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Upon LPA entry, S1 was only staff on duty and stepped out of the front door to guide LPA to office next door, leaving two residents unsupervised, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2022
Plan of Correction
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Licensee will submit proof of in-service training for all staff on the facility's policy for resident care and supervision, with proof of training material, to CCL by POC due date.
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: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022


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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PATHWAY HOMES
FACILITY NUMBER: 157209133
VISIT DATE: 08/29/2022
NARRATIVE
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Continued from LIC809.


Deficiencies are being cited based on LPA observation, interview, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A civil penalty is being assessed in the amount of $100 per day, for a maximum of 5 days, for a total of $500. See LIC421BG for more details.


The following updated forms to be sent to CCL within 2 weeks:
LIC500, LIC308, LIC610E, Proof of Liability insurance

Exit interview conducted. A copy of this report and a Plan of Correction was reviewed and developed with Licensee Jason Johnson, whose signature confirms receipt of this report. Appeal rights were provided to Licensee as well.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
LIC809 (FAS) - (06/04)
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