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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209211
Report Date: 10/28/2024
Date Signed: 10/28/2024 10:48:13 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/17/2024 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240917081535
FACILITY NAME:PATHWAY HOME CAREFACILITY NUMBER:
157209211
ADMINISTRATOR:JOHNSON, JAIMYFACILITY TYPE:
740
ADDRESS:410 LANSING DRIVETELEPHONE:
(661) 836-5705
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:6CENSUS: 4DATE:
10/28/2024
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Supervisor Diana DiazTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Questionable Death
Staff did not have CPR training resulting in an improper medical intervention
Staff did not seek timely medical assistance for resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/28/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings on the above allegation. LPA introduced self, stated the purpose of the visit and met with Supervisor Diana Diaz.

During the course of the investigation, the Department conducted interviews and reviewed records. Based on records reviewed and interviews conducted, there was insufficient evidence to prove or disprove that the death of R1 was questionable. CPR was performed and 911 was called when R1 was choking. S1 have current CPR training completed.

Based on record reviewed and interviews which were conducted, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. Exit interview was conducted. A copy of this report was provided to Supervisor, whose signature confirms receipt of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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