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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601021
Report Date: 07/05/2024
Date Signed: 07/05/2024 09:54:08 AM

Document Has Been Signed on 07/05/2024 09:54 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:STRIDES INCLUSION CENTERFACILITY NUMBER:
415601021
ADMINISTRATOR/
DIRECTOR:		MOCK, RYANFACILITY TYPE:
775
ADDRESS:355 GELLERT BLVD, STE 100TELEPHONE:
(510) 342-6046
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 60CENSUS: 30DATE:
07/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:52 AM
MET WITH:Angie JacobTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
NARRATIVE
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On 7/5/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management visit regarding an incident report. LPA met with Case Manager, Angie Jacob. LPA explained the purpose of today's visit.

On 7/3/24 LPA received a report regarding a staff (S1) slapped client R1 on the cheek due to R1 taking a bit of food from S1’s lunch.

LPA interviewed Staff (S2) who witnessed the incident. S2 stated that the slap S1 did was light and looks more like a tap on the cheek. R1 didn’t have any mark on the cheek. S2 mentioned that the action looked more of an initial reaction and that there was really no intention to hurt R1. S1 is currently on leave and was given a verbal warning regarding the incident.

Deficiency is being cited today as the facility did not ensure that the resident's personal rights is not violated.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. Failure to correct the deficiencies may result in civil penalties. Due to the deficiency being a repeat violation, a civil penalty is being assessed for repeat violation of 82072(a)(3) in the amount of $250.

Report was discussed and a copy of the report & appeals rights is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2024
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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Document Has Been Signed on 07/05/2024 09:54 AM - It Cannot Be Edited


Created By: Grace Donato On 07/05/2024 at 09:32 AM
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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: STRIDES INCLUSION CENTER
FACILITY NUMBER: 415601021

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/06/2024
Section Cited
CCR
82072(a)(3)

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82072 Personal Rights(a) Each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation...or aids to physical functioning.
This requirement is not met as evidenced by:
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Licensee/Administrator to submit a plan to conduct in-service training for the staff regarding residents Personal Rights and Types of Abuse. Submit the plan to LPA by 7/06/24 and in-service training log once available.
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Based on interview, S1 has violated R1s personal rights by slightly tapping R1s cheek when R1 ate S1's lunch which poses an immediate health, safety, or personal rights risk to persons in care.
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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:Andrea Medlin
LICENSING EVALUATOR NAME:Grace Donato
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2024


LIC809 (FAS) - (06/04)
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