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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803676
Report Date: 09/08/2022
Date Signed: 09/08/2022 04:22:58 PM

Document Has Been Signed on 09/08/2022 04:22 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: 4DATE:
09/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:49 PM
MET WITH:Alongia Jenkins, StaffTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Case Management- Incident visit in response to Client (C1’s) Death Report that was submitted on 9/5/2022. LPA explained the purpose of today's visit to staff Alongia Jenkins and conducted a health & safety check of clients in care. Administrator was explained the purpose of the visit telephonically.

During today's visit LPA toured the facility and reviewed client (C1's) file. No signs of neglect, abuse or other immediate health and safety threats were observed. LPA obtained copies of the following documents:
    · Face Sheet
    · Physician’s Report
    · IPP
    · Preplacement Appraisal
    · Medication Administration Records (August 2022 & September 2022)
    · Client Roster
    · LIC 500 Personnel Report
    · Copy of law enforcement card/report #
    · Coroner’s Report #

LPA requested the facility obtain a copy of the death certificate from LA County Registrar's office, and the LA County Coroner's autopsy report. A copy of the death certificate and autopsy report shall be provided to Community Care Licensing upon receipt.


An exit interview was conducted and a copy of the report was provided to staff Alongia Jenkins.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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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