198600005-4-7-2023-11-AS-ASOO-CQEV7Q-20230330161131

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600005
Report Date: 03/30/2023
Date Signed: 04/07/2023 11:57:23 AM

Document Has Been Signed on 04/07/2023 11:57 AM - 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 CARE		FACILITY NUMBER:	198600005
ADMINISTRATOR:	ANA PATRICIA MELGOZA		FACILITY TYPE:	735
ADDRESS:	25052 ESHELMAN AVE.		TELEPHONE:	(310) 784-0624
CITY:	LOMITA	STATE: CA	ZIP CODE:	90717
CAPACITY: 4		CENSUS: 3	DATE:	03/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Patty Navarro, Adminsitrator		TIME COMPLETED:	03:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual inspection visit to the above facility. LPA was met by Zenie Delosantos, Care giver and alter met with Patty Navarro, Adminsitrator the purpose of today’s visit was explained.

There are currently (3) Harbor Regional Center consumers in placement. All (3) clients are ambulatory. (0) non-ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 5 bedrooms, 2 1/2 bathrooms, family room/office, Kitchen, living room, dining room, laundry area and attached 2 car garage.

LPA and Care giver toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. INFECTIOUS CONTROL PRACTICES - LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the family room/office and garage. LPA observed staff wearing masks, client private rooms will be converted to isolation rooms (if needed) No -trash cans with lids, No-cart for PPE’s, Infectious Control Plan posted and/or in folder, Emergency infectious Plan posted and/or in folder, and required postings throughout the facility. Visitor designated area, client’s temperatures are checked and logged (once a day). Emergency contacts updated and posted; PPE's are enough for 30 days. All clients and staff are vaccinated and boosted.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STRIDE FORWARD II ADULT RESIDENTIAL CARE	FACILITY NUMBER: 198600005
	VISIT DATE: 03/30/2023

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STAFFING AND PERSONNEL RECORD TRAINING - 4 staff file is current with valid CPR cards, no signal system needed, Internet access along with computer. CLIENTS RIGHTS /CLIENT RIGHT INCIDENT REPORT- 4 client file are current missing P&I and Functionality Capability Assessment. FOOD SERVICE - Ample supply of perishable and nonperishable food. Kitchen cabinet door next to fridge is broken. OPERATIONAL REQUIREMENT - shaded area, indoor and outdoor activity area, PHYSICAL PLANT ENVIRONMENTAL - Bedrooms 1 - 4 are occupied by clients and contain the mandated furniture. There is 1 staff bedrooms. The (2 1/2) bathrooms are clean and operational. (1) fire extinguisher is fully charged. First Aid kit with Manual, water temperature is at 118.7 degrees Fahrenheit. Linens and personal hygiene supplies are adequate. A comfortable temperature is maintained in the facility. Smoke detectors and carbon monoxide detector are complying and operational. hazardous toxins and/or items are inaccessible to clients. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Exit, walkways and/or passageways, front yard and back yard are free of debris and/or hazards. The facility is in good repair. HEALTH RELATED SERVICES – The MARS is updated and complete. Clients medication are being given as prescribed by their physician. INCIDENTAL MEDICAL SERVICES – The clients do not have any restricted health condition needing specialized care. DISASTER PREPAREDNESS – The facility has an emergency and disaster plan, staff knows were shut off valves are located, flash lights available, cell phones, additional emergency provisions, and conducted fire drill on 12/2022. EMERGENCY INTERVENTION – Staff have valid CPI card.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STRIDE FORWARD II ADULT RESIDENTIAL CARE	FACILITY NUMBER: 198600005
	VISIT DATE: 03/30/2023

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Technical Advisories (TA) issued.

1. No -trash cans with lids

2. No - cart for PPE’s

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies and issued citations.

An exit interview was conducted with Patty Navarro, Administrator and a hard copy of report was provided and Appeal Rights via email.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/07/2023 11:57 AM - It Cannot Be Edited

Created By: Ana Soto On 03/30/2023 at 02:18 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: 03/30/2023

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
1 2 3 4	Based on observation, kitchen cabinet door next to fridge is broken, the licensee did not comply with the section cited above in 1 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/15/2023
	Plan of Correction
1 2 3 4	Administrator to provide picture of repair and send to LPA.

Type B

Section Cited

CCR

85068.2(b)(1)(F)

Needs and Services Plan

(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on R#1 missing Functional Capability Assessment, the licensee did not comply with the section cited above in [2] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/15/2023
	Plan of Correction
1 2 3 4	Administrator to proivde picture complete document and send to LPA.

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:

Janae Hammond

LICENSING EVALUATOR NAME:

Ana Soto

LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

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