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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601021
Report Date: 12/07/2023
Date Signed: 12/07/2023 10:54:14 AM

Document Has Been Signed on 12/07/2023 10:54 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:MOCK, RYANFACILITY TYPE:
775
ADDRESS:355 GELLERT BLVD, STE 100TELEPHONE:
(510) 342-6046
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 60CENSUS: 30DATE:
12/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Ryan Mock, Matthew CanonTIME COMPLETED:
10:45 AM
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On 12/7/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management visit regarding an incident report. LPA met with Program Director, Ryan Mock & Administrator, Matthew Canon. LPA explained the purpose of today's visit.

On 12/01/23 Licensing received an incident report regarding medication administration. Staff gave the medication to the resident (R1) that was provided by the facility where R1 resides. After giving it to R1, staff (S1) noticed that it was a different medication.

Based on interview with staff (S2), when S1 realized it was the wrong medication, he/she reported it right away. S2 called the home and advised them of the wrong medication sent to facility. PCP was called and it was advised to observe the resident. The other medication that was administered was supposed to be given to R1 every 3pm at the home facility.

R1 was observed not to have any adverse effects and was well during the day.

Facility is currently scheduling staff training for Medication Administration and will send LPA in-service training log once done.

No deficiency is being cited today.

Report is reviewed and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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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