Pathway Homes

Type of visit: Case Management - Other

On 3/6/23 at 1:07 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - other inspection to amend the report issued on 12/28/22. LPA explained reason for inspection and met with Licensee (LIC) Jason Johnson. LPA amended LIC9099 issued on 12/28/22 to the facility. No deficiencies cited during this inspection. Exit interview conducted. A copy of this report was given to Licensee Jason Johnson, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Mar 6, 2023

Allegation investigated: Staff failed to provide assistance to resident resulting in falls while in care.

This is an amended report. On 12/28/22 at 11:00 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a complaint inspection. LPA explained reason for inspection and was granted entry by staff. Licensee/Administrator (LIC) Jason Johnson was unavailable for the inspection but was available by telephone at which time the findings of the investigation were delivered. Today, 3/6/23, LPA arrived at the facility unannounced to amend the investigation findings delivered on 12/28/22, as follows. LPA announced reason for visit and met with Licensee Jason Johnson. During the investigation, LPA reviewed records and conducted interviews. Based on review, R1 had some falls at the facility however there was not sufficient evidence to prove that the falls were the result of staff not providing assistance to R1, therefore the allegation is unsubstantiated. Exit interview conducted. A copy of this report was given to Licensee Jason Johnson, whose signature confirms receipt of this report. Unsubstantiated This report was amended.the state’s words, verbatim · CDSS document, Dec 28, 2022 · control 24-AS-20221010164309

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jan 18, 2023

This report was amended. 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)...residents...shall have all of the following personal rights: (4) To care, ...services that meet their individual needs ... This requirement is not met as evidenced by: This report was amended. Based on records review and interviews, LPA found that LIC and S1 admitted to telling R1 to transfer or move by R1’s self because R1 can do it. LIC states R1 is stubborn and refuses to use the wheelchair or walker to assist R1’s self with transfers or moving about, which has resulted in falls. R1’s records show R1 has extensive assistance need for bed mobility, transfers, and movement within the residence. Which poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 28, 2022

Plan of correction: This report was amended. Licensee will submit proof of a new care plan for R1 and proof of an in-service training, with roster, for all staff about R1's new care plan, to CCL by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Darius Wiliams conducted an unannounced Annual Inspection visit. LPA Williams met with Administrator, Jason Johnson and Manager, Elizabeth Ramos and discussed the purpose of the visit. LPA Williams toured the facility with the Manager. LPA Williams observed a visitor/temperature log, masks, and disinfection station at the front entrance. Facility has one entry and exit point. LPA Williams observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies and medications were observed behind a locked door. LPA Williams observed all facility staff wearing masks. Staff have received training regarding Covid-19 infection control and mitigation. 4 of 4 residents had updated emergency contact information. LPA Williams requested the following documents be sent to the Department by 11/23/2022; designation of facility responsibility (LIC 308) and Administrator certificate. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 17, 2022

Type of visit: Case Management - Incident

On 7/14/22 at 10:45 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - incident inspection. LPA explained reason for inspection and was granted entry. LPA met with Co-Administrator Elizabeth Ramos. Licensee (LIC) Jason Johnson arrived a short time later. CCL received a Special Incident Report (SIR) for an incident that occurred on 5/18/22. On 5/18/22, staff (S1) discovered the overflow bottle of Acetaminophe/codei 300-30 mg Qty: 90 for R1 that was filled on 5/11/22 was missing as S1 was getting ready to log the start date of the overflow bottle for the next day's administration. LIC conducted an internal investigation and could not substantiate a finding. LIC reported the incident to Bakersfield Police Department. LPA reviewed records and conducted interviews. A deficiency is being cited based on LPA's interviews and records review in accordance with the CCR Title 22. See LIC 809D. Exit interview conducted. A copy of this report and appeal rights were given to Licensee Jason Johnson, whose signature confirms receipt of this report. A Plan of Correction was made with Licensee Jason Johnson.the state’s words, verbatim · CDSS document, Jul 14, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 15, 2022

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: LPA found that on 5/18/22, staff (S1) discovered the overflow bottle of Acetaminophe/codei 300-30 mg Qty: 90 for R1 that was filled on 5/11/22 was missing as S1 was getting ready to log the start date of the overflow bottle for the next day's administration, this poses an immediate health or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 14, 2022

Plan of correction: Licensee started a new procedure for narcotic medication administration following the incident. Licensee will submit proof of the written procedures for narcotic medication administration to CCL by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst LPA Shawna Doucette conducted an Annual Infection Inspection on this date. LPA was met by Staff Lupe Garcia and discussed the purpose of the visit. LPA and House Manager Elizabeth Ramos began the tour at the front entrance of the facility. Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Covid-19 related signs were observed in the common areas. LPA did not observe hand washing signs. Cleaning supplies were observed behind a locked cabinet door in garage. LPA observed the following personal protective equipment in a storage cabinet ; hand sanitizer and masks. LPA did not see any N95 masks or gloves. Facility did have training records for infection control training. LPA observed all facility staff to be wearing masks upon arrival. LPA provided facility with gloves, N95 masks and gowns. Resident’s files have been updated emergency contact information. Exit interview was conducted and a copy of this report was providedthe state’s words, verbatim · CDSS document, Nov 29, 2021

Type of visit: Case Management - Health Checks

Licensing Program Analyst LPA conducted a Case Management to follow up on issues listed in NCC meeting. LPA was met by Staff Lupe Garcia and discussed the purpose of the visit. LPA and House Manager Elizabeth Ramos began the tour at the front entrance of the facility. LPA Shawna Doucette and House Manager toured the facility. LPA observed there not to be a two day supply of perishable food and seven day supply of non-perishable food. LPA interviewed staff and residents. LPA reviewed resident records and staff records. Deficiencies are being cited based on LPA's observation and record review in accordance with the CCR Title 22. See LIC 809D. An exit interview was conducted with House Manager Elizabeth Ramos and a copy of this report with Plans of Corrections and appeal rights was provided to Licensee Jason Johnson.the state’s words, verbatim · CDSS document, Nov 29, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(26) · Plan of correction due date: Dec 3, 2021

87555 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 was not met: Based on observation and interviews Licensee does not have a minimum of one week nonperishable foods or a minimum of two days of perishable maintained at the facilty which poses a potential Health, Safety or personal rights risk to the clients in care.the state’s words, verbatim · CDSS document, Nov 29, 2021

Plan of correction: Plan of Correction POC Licensee agrees to submit a receipt of food containing all food groups by POC due date 12/3/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87507(c) · Plan of correction due date: Dec 3, 2021

87507 Admission Agreements (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement was not met as evidenced by: Based on review of records Licensee did not have a signed admissions agreement for R1, which poses a potential Health, Safety or personal rights risk to the clients in care.the state’s words, verbatim · CDSS document, Nov 29, 2021

Plan of correction: Plan of Correction Licensee agrees to have R1's documents signed and submitted by POC due date 12/3/21.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(3)(B) · Plan of correction due date: Dec 31, 2021

87608 Postural Supports (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement was not met by Based on observation and records review R1 did not have a physician order for full bed rails which poses an immediate Health, Safety or personal rights risk to the clients in care.the state’s words, verbatim · CDSS document, Nov 29, 2021

Plan of correction: Plan of Correction POC Licensee agrees to obtain a doctors order for full bed rails by POC due date 12/31/21

From the deficiency page — Deficiency type: Type B · Section cited: CCR80065(g)(2) · Plan of correction due date: Dec 31, 2021

80065 Personnel Requirements(g) All personnel, including the licensee, administrator and volunteers, shall be in good health, and shall be physically, mentally, and occupationally capable of performing assigned tasks.(2) A health screening report signed by the person performing such screening shall be made on each person specified above, and shall indicate the following:(A) The person's physical qualifications to perform the duties to be assigned. This requierment was not met evidenced by: Based on review of records staff did not have Health Screening signed by a physician which poses a potential Health, Safety or personal rights risk to the clients in care.the state’s words, verbatim · CDSS document, Nov 29, 2021

Plan of correction: Plan of Correction POC Licensee agrees to submit Health Screening for all staff by POC due date 12/31/21

Allegation investigated: Lack of supervision.

On 10/21/21 at 10:45 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a complaint investigation and deliver findings. LPA met with Licensee (LIC) Jason Johnson. During the course of the investigation, LPA made observations, conducted interviews, and reviewed records. Based on observations, interviews, and record review, LPA found that staff are listed as scheduled at both facility and LIC's facility next door. LIC admits staff will go work at facility next door to help and is not barred from doing so when working alone. The above allegation is substantiated. Deficiency is being cited based on LPA observations, interviews, and record review in accordance with the California Code of Regulations, Title 22, see LIC9099D. Exit interview conducted. A copy of this report and appeal rights were discussed and emailed to facility's email address on record, with "Read receipt" to confirm receipt of this report. Substantiatedthe state’s words, verbatim · CDSS document, Oct 21, 2021 · control 24-AS-20210518103524

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Oct 28, 2021

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by: Based on observations, interviews, and record review, LPA found that staff are listed as scheduled at both facility and LIC's facility next door. LIC admits staff will go work at facility next door to help and is not barred from doing so when working alone. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 21, 2021

Plan of correction: Licensee will submit proof of new staff schedule for each separate facility by POC due date.

Type of visit: Office

A Non-Compliance Conference meeting was held on 07/12/2021 at the Fresno Regional Office. The purpose of the Non Compliance Conference was to discuss recently identified issues/concerns associated with the operation of the facility. The Non-Compliance conference process was explained during this meeting. The following were in attendance: Jason Johnson, Licensee/Administrator Brenda White, Regional Manager Melinda Hoffmann, Licensing Program Manager Sergiy Pidgirny, Licensing Program Manager Shawna Doucette, Licensing Program Analyst Malia Thao, Licensing Program Analyst Licensee was provided with copies of all applicable regulations and/or Health and Safety Codes.the state’s words, verbatim · CDSS document, Jul 12, 2021