198600005-4-9-2025-11-AS-JANO-DFKVCR-20250409161935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600005
Report Date: 04/09/2025
Date Signed: 04/09/2025 04:19:50 PM

Document Has Been Signed on 04/09/2025 04:19 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	STRIDE FORWARD II ADULT RESIDENTIAL CARE		FACILITY NUMBER:	198600005
ADMINISTRATOR/ DIRECTOR:	ANA PATRICIA MELGOZA		FACILITY TYPE:	735
ADDRESS:	25052 ESHELMAN AVE.		TELEPHONE:	(310) 784-0624
CITY:	LOMITA	STATE: CA	ZIP CODE:	90717
CAPACITY: 4		CENSUS: 4	DATE:	04/09/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Administrator - Anna P. Navarro		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 04/09/2025, Licensing Program Analyst (LPA) Jose Anguiano and LPA Socorro Leandro, conducted an unannounced annual required visit using the CARE Inspection Tool. LPA Anguiano met with Administrator Ana P. Navarro and explained the purpose of today’s visit. The facility is licensed for 4 Ambulatory Developmentally Disabled Adults Ages 15 thru 59. The facility consists of the following: 1 Kitchen, 1 Dining Room with an Office area, 1 Living Room, 4 Client Bedrooms, 1 Staff Ensuite Room with an attached Bathroom, 1 Client Ensuite Room with an attached Toilet Room, 3 Client Bedrooms, 1 Bathroom, 1 attached Garage, 1 Backyard with a shaded Patio area.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Jose Anguiano
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 04/09/2025 04:19 PM - It Cannot Be Edited

Created By: Jose Anguiano On 04/09/2025 at 03:06 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: STRIDE FORWARD II ADULT RESIDENTIAL CARE	FACILITY NUMBER: 198600005
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having obstructions and potential hazards in the facility outdoor walkway, garage, and staff room which poses a potential safety risk to persons in care and staff.
	POC Due Date: 05/13/2025
	Plan of Correction
1 2 3 4	The Administrator has agreed to clean up, clear, and organize the outdoor walkway, garage, and staff room. Photos of will be emailed to Jose.Anguiano@dss.ca.gov .

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Stephanie Cifuentes
NAME OF LICENSING PROGRAM MANAGER:

	Jose Anguiano
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: STRIDE FORWARD II ADULT RESIDENTIAL CARE	FACILITY NUMBER: 198600005
	VISIT DATE: 04/09/2025

NARRATIVE

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LPAs toured the physical plant. Sufficient storage areas for kitchen supplies, linens, medications (secured) and chemicals (secured). There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. Outside walkways around the facility are not free from obstructions there is a mattress, and other materials might be a potential hazard to clients in care. It is difficult to walk through the staff room and garage and both areas are not free from obstructions.

Bathrooms were operational. Hot water temperature measured at 110 F.

LPAs observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and 2 days supplies perishable, and 7 days non-perishable food was maintained.

Fire extinguishers were charged, and smoke detectors and carbon monoxide were present. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. During the visit, LPAs observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted including Activities Calendar and Food Menu.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Jose Anguiano
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: STRIDE FORWARD II ADULT RESIDENTIAL CARE	FACILITY NUMBER: 198600005
	VISIT DATE: 04/09/2025

NARRATIVE

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LPA conducted an audit of 4 resident records, and 5 personnel records. The administrator certificate is valid. The facility has a Liability Insurance Certificate valid through 03/01/2026. The facility Surety Bond valid through 08/29/2025.

A Technical Assistance is being provided regarding the updated Emergency and Disaster Plan, Infection Control Plan and training regarding both documents.

A deficiency is being provided regarding potential hazards / facility being kept free of obstructions.

An exit interview was conducted, a plan of correction was developed with the Administrator and a copy of the report and appeals rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Jose Anguiano
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025

LIC809 (FAS) - (06/04)

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