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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804206
Report Date: 04/08/2024
Date Signed: 04/09/2024 12:07:10 PM

Document Has Been Signed on 04/09/2024 12:07 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SUCCESSFUL STRIDES INCFACILITY NUMBER:
486804206
ADMINISTRATOR/
DIRECTOR:
REESE, LORIFACILITY TYPE:
735
ADDRESS:106 SERRA DRIVETELEPHONE:
(650) 269-2328
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 4CENSUS: 1DATE:
04/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Lori Reese, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:36 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived to conduct a pre-licensing inspection and was greeted by Licensee/Administrator, Lori Reese.

At approximately 1:40PM LPA and Administrator toured the building and grounds. Facility is a three level residence with three bedrooms upstairs in the top floor. Master bedroom with full bathroom, that will be used by staff; 2 client bedrooms and a hallway bathroom. The main level of the home is made of family room, living room dining room, kitchen , bathroom and clients room. The lower level of the home has an additional bedroom that may be used by clients, a bonus room/living room. Top floor and main floor both have wooden decks and the lower floor has a backyard area. All client rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table.

There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Cleaning supplies and toxins are inaccessible to clients. Facility has areas inside and outside for visiting and activities. There was an appropriate supply of linens, hygiene products and paper products available for clients.

Facility received an approved fire clearance dated November 20, 2023 for four (4) ambulatory clients by the Vallejo Fire department. LPA observed charged fire extinguishers in every floor. Facility was informed to ensure they have proof of purchase or service on file, fire extinguishers must be serviced yearly and facility must keep proof. Smoke detectors and carbon monoxide detectors were tested and operational.


Continue report see LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SUCCESSFUL STRIDES INC
FACILITY NUMBER: 486804206
VISIT DATE: 04/08/2024
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Facility has an Infection Control plan and Emergency Disaster Plan on file. Hot water temperatures found to be within Title 22 Regulations of 105 to 120 degrees Fahrenheit. Component III was conducted with Applicant.
Lori Reese, Administrator Certificate 6065428735 expires 10/15/2025.

No Deficiencies or Advisories given during visit. Pre-Licensing completed. Facility currently has a foster care license and provides care to 3 individuals, of which two have been notified and applicant is waiting for them to be placed at another home. LPA will review file and applicant will be notified regarding licensure.

LPA will then submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicant of Status.

Do to computer and tool kit issues, this report was emailed to applicant along with several links to review and sign up for informational PINS and Guardian.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024
LIC809 (FAS) - (06/04)
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