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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600005
Report Date: 07/11/2022
Date Signed: 07/11/2022 07:29:21 PM

Document Has Been Signed on 07/11/2022 07:29 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:STRIDE FORWARD II ADULT RESIDENTIAL CAREFACILITY NUMBER:
198600005
ADMINISTRATOR:ANA PATRICIA MELGOZAFACILITY TYPE:
735
ADDRESS:25052 ESHELMAN AVE.TELEPHONE:
(310) 784-0624
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 4CENSUS: 4DATE:
07/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:Administrator - Ana Patty NavarroTIME COMPLETED:
04:15 PM
NARRATIVE
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On 07/11/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA and was greeted by caregiver Estrelita Dapar and later joined by Administrator Ana “Patty” Navarro and explained the purpose of today’s visit. The facility is licensed to operate for four (4) ambulatory developmentally disabled adults of between the ages of 18 through 59.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client rooms, one (1) staff room with a bathroom, one (1) office space near the back, two (2) bathrooms with one (1) of them shared, a living area, a dining area and kitchen. There is an patio area in the backyard with an umbrella used for shade. The laundry area is located in the hallway next to the dining area. The garage is attached and used for storage only.

LPA and caregiver toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were operational. The water temperature did not meet Title 22 standards in the bathrooms and kitchen sink – see LIC 809 D page. A comfortable temperature was maintained in the facility.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2022
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 10
Document Has Been Signed on 07/11/2022 07:29 PM - It Cannot Be Edited


Created By: Don Senaha On 07/11/2022 at 03:13 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STRIDE FORWARD II ADULT RESIDENTIAL CARE
FACILITY NUMBER: 198600005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022

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 as LPA observed a knife, scissors and screwdriver unlocked in kitchen drawers which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2022
Plan of Correction
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LPA witnessed Administrator locking the sharps immediately following inspection.
Type A
Section Cited
CCR
80087(g)(1)
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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 as LPA observed toxins under the kitchen sink unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2022
Plan of Correction
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LPA witnessed Administrator locking the toxins immediately following inspection.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 07/11/2022 07:29 PM - It Cannot Be Edited


Created By: Don Senaha On 07/11/2022 at 03:13 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STRIDE FORWARD II ADULT RESIDENTIAL CARE
FACILITY NUMBER: 198600005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 as LPA measured water in restrooms and kitchen to measure between 97.2 F and 97.8 F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2022
Plan of Correction
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 07/11/2022 07:29 PM - It Cannot Be Edited


Created By: Don Senaha On 07/11/2022 at 03:13 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STRIDE FORWARD II ADULT RESIDENTIAL CARE
FACILITY NUMBER: 198600005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 as LPA observed dirty dishes and food on floor in kitchen which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2022
Plan of Correction
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Administrator immediatley cleaned up the dirty dishes and food on the floor and table.
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

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 as LPA observed the side of the house filled with obstruction items which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2022
Plan of Correction
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LPA and Administrator discussed clearing obstructions in pathways by POC date.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 07/11/2022 07:29 PM - It Cannot Be Edited


Created By: Don Senaha On 07/11/2022 at 03:13 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STRIDE FORWARD II ADULT RESIDENTIAL CARE
FACILITY NUMBER: 198600005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview with staff and record review, the licensee did not comply with the section cited above ias LPA reviewed Medication Administration record missing for client which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2022
Plan of Correction
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Administrator to send copy of missing record to LPA by POC due date.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022


LIC809 (FAS) - (06/04)
Page: 10 of 10
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: STRIDE FORWARD II ADULT RESIDENTIAL CARE
FACILITY NUMBER: 198600005
VISIT DATE: 07/11/2022
NARRATIVE
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LPA observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene was available for each client. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. There is one (1) fire extinguisher fully charge located next to the laundry area. Smoke detectors and carbon monoxide were operable and in working condition.

During the visit, LPA observed the facility infection control practices. LPA observed hand sanitizer available and temperature taken after entry to the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). There is a fully stocked first aid kit in the file cabinet.

There were six (6) deficiencies cited during this inspection visit. There were four (4) technical advisories issued on LIC 9102 forms.

An exit interview was conducted and a copy of this report was provided to Administrator Ana “Patty” Navarro.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC809 (FAS) - (06/04)
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