<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209376
Report Date: 04/25/2024
Date Signed: 04/25/2024 12:14:19 PM

Document Has Been Signed on 04/25/2024 12:14 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 HOME CAREFACILITY NUMBER:
157209376
ADMINISTRATOR/
DIRECTOR:		JONHSON, JAIMYFACILITY TYPE:
740
ADDRESS:416 LANSING DRIVETELEPHONE:
(661) 972-6051
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 3DATE:
04/25/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:37 AM
MET WITH:House Manager Diana DiazTIME VISIT/
INSPECTION COMPLETED:
12:06 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Darius Williams conducted an unannounced Post Licensing visit.

LPA Williams toured the facility.

Living room had space to accommodate all residents. Thermostat reflected 71 degrees Fahrenheit.

Two bedrooms were observed that had two beds in each. Mattress (with required linens), night stand, chair, dresser, and working lights were present and operational.

One bathroom is available for resident use. Water was functioning and Non-slip strips and grab bars were available for use.

LPA reviewed 3 resident files. All 3 files did not have documentation of a Resident Appraisal. House Manager reported they utilize a Department of Health Care Services plan as their Appraisal. LPA informed them that the facility must conduct their own appraisal and will utilize the DHCS document as supporting information.

A deficiency is being cited on the attached LIC 809D.

An exit interview was conducted and a copy of this report and appeal rights were provided.


SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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 04/25/2024 12:14 PM - It Cannot Be Edited


Created By: Darius Williams On 04/25/2024 at 12:03 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 HOME CARE
FACILITY NUMBER: 157209376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2024
Section Cited
CCR
87457(c)(1)(A)

1
2
3
4
5
6
7
(A) The licensee shall be permitted to use the form LIC 603 (Rev. 6/87), Preplacement Appraisal Information, to document the appraisal.

This requirement was not met evident by:
1
2
3
4
5
6
7
Licensee agreed to complete Appraisal with resident and submit to the Department by POC due date of 5/2/2024.

Additionally, LPA is referring facility to the Technical Support Program.
8
9
10
11
12
13
14
Licensee did not ensure Pre-Appraisal was completed for 3 of 3 residents which poses a potential health/safety risk and/or personal rights violation to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Serigy Pidgirny
LICENSING EVALUATOR NAME:Darius Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2