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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803676
Report Date: 06/20/2023
Date Signed: 06/20/2023 04:48:39 PM

Document Has Been Signed on 06/20/2023 04:48 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: 4CENSUS: 4DATE:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Marina Rios, Assistant AdministratorTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Assistant Administrator Marina Rios. There are four (4) ambulatory developmentally disabled residents in the home. The facility is licensed as a level 3 Adult Residential Facility (ARF) vendored by San Gabriel/Pomona Regional Center.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. Visitor screening is no longer in place. Resident bedroom's are designated as a COVID-19 isolation room if needed. Infection Control Plan and COVID-19 Mitigation Plan have been submitted.


Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential neighborhood that is licensed for four (4) 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 interior and exterior physical plant was inspected. Exit doors are free of any obstruction. Smoke and carbon monoxide detectors are operational. The facility has one (1) fully charged fire extinguisher. Cleaning supplies and toxic substances are inaccessible to residents.

  • Water temperature readings did not measure between the required 105 - 120 degrees Fahrenheit. Citation was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: STRIDE
FACILITY NUMBER: 197803676
VISIT DATE: 06/20/2023
NARRATIVE
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Operational Requirements:
  • The Program Design was reviewed.
  • On 11/30/2022, revised Fire Clearance was approved by LA County Fire Department for four (4) ambulatory clients due to a change of capacity.
  • Care and supervision to meet the clients needs was observed. No special equipment was observed.
  • The Surety Bond is current in the amount of $1,000.00

Staffing:
  • A total of three (3) staff members provide care and supervision to residents. The facility is owner operated.

Personnel Records/Staff Training:
  • Administrator certificates expires 8/5/2023.
  • Three (3) staff files were reviewed for criminal background clearance and training.
  • Personnel records were reviewed for health/TB screenings, certifications, and 1st Aid/CPR training.

Resident Rights/Information:
  • No Physician orders for postural supports are in place.

Resident Records/Incident Reports:
  • Four (4) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, medication records, Restricted Health Care Plans, and P & I money were reviewed.

Food Service:
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
  • Residents do not have any modified diets.

See next page.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
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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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: STRIDE
FACILITY NUMBER: 197803676
VISIT DATE: 06/20/2023
NARRATIVE
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Health Related Services:
  • Residents are assisted with self administration of prescription and non-prescription medications.
  • Four (4) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.

Incident Medical and Dental:
  • All residents have a Needs and Services Plan an on file.
  • Staff training was on file.

Disaster Preparedness, and Emergency Intervention:
  • An Emergency Disaster Plan LIC 610D containing emergency evacuation information was reviewed.
  • An emergency drill was conducted on 3/30/2023. The facility shall conduct a drill at least quarterly for each shift.


Emergency Intervention:
  • No manual restraints or seclusion are used on residents in care.


No deficiencies cited.

Exit interview 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: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/20/2023 04:48 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/20/2023 at 04:09 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: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 kitchen knives were stored unlocked in a kitchen cabinet; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2023
Plan of Correction
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Assistant Administrator immediately removed the knives and stored them in a locked closet. ***CLEARED
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 hot water temperature readings were 126.7, 122.1, 124.3 degrees Fahrenheit; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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Administrator shall submit a water temperature log with time/ hot water readings tested 3 times a day. Submit by tomorrow.
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: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/20/2023 04:48 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/20/2023 at 04:09 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: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(4)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths.

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 none of the resident beds had mattress pads; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2023
Plan of Correction
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Administrator shall submit proof that mattress pads were purchased and placed on all resident beds.
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: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
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