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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209157
Report Date: 08/29/2022
Date Signed: 08/29/2022 01:09:13 PM

Document Has Been Signed on 08/29/2022 01:09 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:
157209157
ADMINISTRATOR:JOHNSON, JASONFACILITY TYPE:
740
ADDRESS:2714 GOSFORD RD #BTELEPHONE:
(661) 972-6235
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 6CENSUS: 4DATE:
08/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Jason Johnson, Licensee/AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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On 8/29/2022 at 9:10 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced for a case management - deficiency inspection.

LPA was conducting an inspection at Pathway Homes #157209133 when staff called S1 for assistance with LPA. S1 entered facility #157209133 through the garage door, which is connected to facility #157209157 by a joined office room. LPA inquired if S1 was the only staff on duty. S1 admitted S1 was the only staff on duty. LPA asked if there were residents in the facility. S1 admitted there were four residents in facility #157209157.

A deficiency is being cited based on LPA observation and interview in accordance with the California Code of Regulations, Title 22, see LIC809D.

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
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 2
Document Has Been Signed on 08/29/2022 01:09 PM - It Cannot Be Edited


Created By: Malia Thao On 08/29/2022 at 12:19 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: 157209157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2022
Section Cited
CCR
87411(d)(3)

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87411 Personnel Requirements – General (d) All personnel shall be given on the job training...(3) Skill and knowledge required to provide necessary resident care and supervision...

This requirement is not met as evidenced by:
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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.
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LPA was conducting an inspection at Pathway Homes #157209133 when staff called S1 for assistance with LPA. S1 entered facility #157209133 through the garage door, which is connected to facility #157209157 by a joined office room. LPA inquired if S1 was only staff on duty. S1 admitted S1 was only staff on duty. LPA asked if there were residents in the facility. S1 admitted there were four residents in facility #157209157. This poses a potential health, safety, 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: 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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