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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209297
Report Date: 05/22/2025
Date Signed: 05/22/2025 06:54:03 PM

Document Has Been Signed on 05/22/2025 06:54 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PATHWAY ASSISTED LIVING/ WESTCHESTER GARDENSFACILITY NUMBER:
157209297
ADMINISTRATOR/
DIRECTOR:		MOREHEAD, NICOLEFACILITY TYPE:
740
ADDRESS:2228 TRUXTUN AVETELEPHONE:
(661) 324-3091
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93301
CAPACITY: 36CENSUS: 34DATE:
05/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Nicole MoreheadTIME VISIT/
INSPECTION COMPLETED:
07:20 PM
NARRATIVE
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On 5/22/2025, Licensing Program Analysts (LPAs) Daiquiri Boyd and Shawna Doucette arrived unannounced at the facility to complete an Annual Inspection. LPAs were met by caregiver staff and were told they had called Administrator (AD) Nicole Morehead and that she was pulling in.
LPAs toured the facility with AD.
Kitchen toured, there was not a sufficient supply of food observed for perishable, as there was only a half gallon of milk for the 34 residents in the facility. There was not a sufficient supply of non-perishable foods on hand, LPAs did not observe a 7 day supply of goods. Facility had menus posted on the dining room wall. LPA's took photos of freezer, refrigerator, and dry goods shelves. In the dining area there is an ice machine where they can get self service ice. AD stated that they receive a weekly supply of food, due for delivery tomorrow and the supplier is Jordano's Supply. There is no supply of diabetic diet foods on hand for residents.

There were 18 resident bedrooms, each room houses 2 residents. Resident rooms all had their own bathrooms. Temperature in room #9 was recorded by LPA at 135.1 degrees F. LPAs observed proper hand rails and grab bars. Non-skid mats were available. Room #16 was toured and the water temperature measured at 127.1 degrees F. Hand washing and personal hygiene items were seen on hand.

A tour of the outside was conducted and a shaded courtyard was observed with tables and chairs for residents to sit and visit. There was an area with trash receptacles appropriate for smoking.

6 resident files and 4 staff records were reviewed. AD reports that they currently only have one bedridden client. Current first aid and CPR were reviewed and found to be in compliance.

(continued on next page)

NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Daiquiri Boyd
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PATHWAY ASSISTED LIVING/ WESTCHESTER GARDENS
FACILITY NUMBER: 157209297
VISIT DATE: 05/22/2025
NARRATIVE
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LPAs reviewed Training Logs and found that only 2 hours of training were completed for the combined dementia and hospice care. R1 has a LIC602 that states that she is bedridden, but the AD stated that she is not bedridden and can repossition. R2 has no care plan from Bristol Hospice Agency. R3 has home health care, but there is no written plan of the division of care and responsibilities of the facility. R3 has a pressure wound and the level of the ulcer is not mentioned in the Home Health Care file, but LVN Naomi Medina on staff, stated that the number assigned is 2. R6 has no Admission Agreement with Kern Regional Center. R7 has a skin tear that appears inflamed, LPAs verified care plan on file and found to be appropriate.

LPAs observed the medication cart in the dining room area. A check of the medications was done by LPA Boyd. LPA Boyd observed that R6 had missed a medication on 5/9/25 and the medication administration log showed that he missed the medication on this date due to being in the hospital. All medications observed to be logged properly.

In the hallway of the facility is a locked storage closet which holds the diabetic medications and/or testing strips. There is a refrigerator in this closet that holds all diabetic and all other refrigerated medications. This refrigerator was observed to be locked upon entry to this closet. In the corner of this closet was a large (approximate 25 gallon) trash can size bio-hazard container with dispensed diabetic injectable pens. On top of this bio-hazard container was several resident snacks, for example: several open boxes of crackers(Ritz, Lays), an open coffee creamer. Pictures were taken by LPAs.

There is a room called the "TV room" which is where the lights signal for the call buttons that are in each of the resident rooms. There is an overflow med cart in this room that stays locked.

Postings for the facility were observed at the end of the hall by entrance doors. Disaster and Emergency plan was not posted and was not complete in the office computer. Last fire drill was on 4/30/25. LPA asked for an updated Disaster Plan.
NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Daiquiri Boyd
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/22/2025 06:54 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 05/22/2025 at 05:32 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 ASSISTED LIVING/ WESTCHESTER GARDENS
FACILITY NUMBER: 157209297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

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 in facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Administrator to check the water temperature in at least two rooms to verify that it is within the guidelines of 105 and 120 degrees F. Administrator will send a picture of the temperature gauge to Licensing.
Deficiency Dismissed
Type A
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

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 in the hall closet it was observed food stored with disposed bio-hazard material which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Food shall be stored in a manner that does not compromise it's integrity. Administrator will provide photos of food stored in a manner that it is not in proximity of bio-hazard matter. Photo to be provided to Licensing by 5/23/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Daiquiri Boyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2025 06:54 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 05/22/2025 at 05:32 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 ASSISTED LIVING/ WESTCHESTER GARDENS
FACILITY NUMBER: 157209297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in all staff counts which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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Administrator to provide proof of training of all staff. Proof to be submitted to Licensing by providing a sign in sheet and the topics covered, date and time of training and who provided this training.
Deficiency Dismissed
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

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 in the kitchen, refrigerator, freezer, and food storage, there is not enough food on hand for residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2025
Plan of Correction
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Administrator to provide proof by photo, that there is a sufficient supply of food, both perishable and non-perishable, on hand for all residents serviced. Photo to be provided to Licensing.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Daiquiri Boyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 05/22/2025 06:54 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 05/22/2025 at 05:32 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 ASSISTED LIVING/ WESTCHESTER GARDENS
FACILITY NUMBER: 157209297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87609(b)(4)
Allowable Health Conditions and the Use of Home Health Agencies
(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of the seven files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2025
Plan of Correction
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Administrator will provide a complete plan from the home health agency that states the expectations of the RCFE. Plan to be submitted to Licensing by email.
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 client files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2025
Plan of Correction
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2
3
4
Administrator will provide a complete plan from the hospice agency that states the expectations of the RCFE. Plan to be submitted to Licensing by email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Daiquiri Boyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 05/22/2025 06:54 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 05/22/2025 at 05:32 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 ASSISTED LIVING/ WESTCHESTER GARDENS
FACILITY NUMBER: 157209297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)(6)(B)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan. (B) The hospice agency will provide training specific to the current and ongoing needs of the individual resident receiving hospice care and that training must be completed before hospice care to the resident begins.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in two out of two files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2025
Plan of Correction
1
2
3
4
Administrator shall provide a plan from the hospice agency for the staff, to train the staff in the responsibilities of the care of the hospice clients. Proof of the plan and the instructions to the staff should be provided to Licensing.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Daiquiri Boyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2025


LIC809 (FAS) - (06/04)
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