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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 10:52:32 AM

Document Has Been Signed on 12/07/2023 10:52 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:
08:46 AM
MET WITH:Ryan Mock, Matthew CanonTIME COMPLETED:
10:45 AM
NARRATIVE
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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 11/ 28/23 Licensing received a report regarding a staff (S1) put a hot glue gun on a residents (R1) neck.

Based on interview with a witness (S2), there was an activity in the main room where some residents are doing a project. S2 had to go and open a door to let a group in who just came from an outing. When S2 turned around to go back to the activity area, he/she saw S1 put a hot glue gun on R1. S2 asked S1 on what they are doing and R1 stood up and walked away. S2 went to check on R1 and saw a red mark on the neck.

Facility investigated the incident and S1 was let go from his/her work.

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

Deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed and a copy of the report & appeals rights 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)
Page: 1 of 2
Document Has Been Signed on 01/04/2024 08:47 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/14/2023 03:47 PM


Created By: Grace Donato On 12/07/2023 at 10:07 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: STRIDES INCLUSION CENTER
FACILITY NUMBER: 415601021

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/08/2023
Section Cited
CCR
82072(a)(3)

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(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 for training of staff with regards to resident's personal rights. Submit the plan to LPA by 12/08/23.
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Based on interviews, S1 has vilated R1s personal rights by putting a hot glue gun on R1s neck 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:April Cowan
LICENSING EVALUATOR NAME:Grace Donato
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


LIC809 (FAS) - (06/04)
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