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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592837
Report Date: 05/12/2022
Date Signed: 05/12/2022 03:10:52 PM

Document Has Been Signed on 05/12/2022 03:10 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CLIMB WORK ACTIVITY CENTERFACILITY NUMBER:
191592837
ADMINISTRATOR:FILIMON GERBERMICHEALFACILITY TYPE:
775
ADDRESS:161 SIERRA MADRE BLVDTELEPHONE:
(626) 355-1447
CITY:SIERRA MADRESTATE: CAZIP CODE:
91024
CAPACITY: 60CENSUS: 53DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Day Program Manager / Isabella FerruscaTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA), Joe Katrdzhyan, conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Day Program Manager / Isabella Ferrusca who assisted with the visit. The facility is licensed as an Adult Day Program for adults between the ages of 18 - 59 years of age who are developmentally disabled, for a capacity of 60 consumers (55 Ambulatory and 5 Non-ambulatory clients only). There are 53 consumers attending today's program. During today's visit, LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured and medications reviewed.

LPA Conducted a facility walk through which consisted of 1 large building with three (3) activity rooms (Workshop, Production Room and Computer Room), office, kitchen, storage room and 2 bathrooms. All rooms have required furniture and equipment necessary to conduct all activities. Documents are posted as mandated by Title 22 Regulations. Smoke detectors were tested throughout the facility and observed to be operational. The fire extinguishers are fully charged and in compliance. Facility has two (2) bathrooms and both have a working toilet and sink. Both bathrooms were clean and operational. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. The first-aid kit is fully stocked w/First-Aid Manual, thermometer, scissors, tweezers, bandages and sterile first-aid dressing. Medications are centrally stored and locked inside the office. Disinfectants and cleaning solutions are kept locked and inaccessible to clients. LPA reviewed client medications.

Consumers are expected to bring their lunch from home as the facility does not provide lunch. The facility does not provide snacks to the consumers. San Gabriel/Pomona Regional Center and East LA Regional Center coordinate with multiple vendors regarding the transportation of consumers to and from their homes.

Please see LIC 809C for additional information.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CLIMB WORK ACTIVITY CENTER
FACILITY NUMBER: 191592837
VISIT DATE: 05/12/2022
NARRATIVE
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The following concern was observed during today's visit;
  • At 9:44am, LPA observed a sharp knife left in the dishwasher, accessible to the consumers.

The following deficiency was observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted and a copy of this report was provided to the Day Program Manager along with the Appeals Rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/12/2022 03:10 PM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 05/12/2022 at 10:24 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CLIMB WORK ACTIVITY CENTER
FACILITY NUMBER: 191592837

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2022
Section Cited

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Buildings and Grounds. Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not being met as evidenced by:
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At 9:44am, LPA observed a sharp knife left in the dishwasher, accessible to consumers. This 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:Wei Siew Ho
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022


LIC809 (FAS) - (06/04)
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