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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803676
Report Date: 05/05/2022
Date Signed: 05/05/2022 04:15:52 PM

Document Has Been Signed on 05/05/2022 04:15 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:STRIDEFACILITY NUMBER:
197803676
ADMINISTRATOR:HUNT, RENEE DENISEFACILITY TYPE:
735
ADDRESS:2059 RAELYN PLACETELEPHONE:
(626) 961-5101
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 6DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:34 PM
MET WITH:Marina Rios, Assistant AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. Staff Alongia Jenkins was explained the purpose of the visit. Assistant Administrator Marina Rios arrived shortly after. The facility is a single story home located in a residential neighborhood that is licensed for six (6) ambulatory only developmentally disabled clients ages 18 - 59. The home consists of three (3) client bedrooms, one (1) staff room, 2 bathrooms, kitchen, dining room, living room, backyard patio area, and attached garage with laundry area. The last fire drill was completed on 12/20/2021. Administrator certificate expired on 8/5/2019.

The following were observed/inspected:

· The interior and exterior physical plant was inspected. LPA was screened upon entry by staff.
· Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical
distancing. Facility has an approved COVID-19 mitigation plan.
· The staff room is designated as the COVID-19 isolation room if needed.
· Five (5) centrally stored client medication records were reviewed.
· Clients in care do not wear masks in the home.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days was observed.
· A posted Emergency Disaster Plan was observed.
· Personal Protective Equipment (PPEs) was observed.
· Ms. Renee Hunt's Administrator certificate expired prior to the COVID-19 pandemic.

A deficiency was cited. See LIC 809D.

Exit interview was conducted with Assistant Administrator Marina Rios. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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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Document Has Been Signed on 05/05/2022 04:15 PM - It Cannot Be Edited


Created By: Noemi Galarza On 05/05/2022 at 03:59 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: STRIDE
FACILITY NUMBER: 197803676

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064.3(d)
Administrator Recertification Requirements. To apply for recertification prior to the expiration date of the certificate, the certificate holder shall submit to the Department's Administrator Certification Section, post-marked on, or up to ninety (90) days before, the certificate expiration date:

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 that the Administrator Certificate expired 8/5/2019, which poses/posed a potential health, safety or personal rights risk to persons in care. Administrator stated she did not complete all the required courses for recertification during the pandemic.
POC Due Date: 06/02/2022
Plan of Correction
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Administrator agreed to submit proof of completed courses, as well as proof that training was submitted to the certification unit.
NOTE: If an extension is needed Administrator shall notify LPA by the POC due date [6/2/2022].
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022


LIC809 (FAS) - (06/04)
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