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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592837
Report Date: 05/16/2023
Date Signed: 05/16/2023 03:56:41 PM

Document Has Been Signed on 05/16/2023 03:56 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: 54DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Residential Director - Hector Vargas TIME COMPLETED:
03:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Calderon conducted the annual inspection with the focus of the Infection control domain. LPA arrived unannounced and met with Residential Director Hector Vargas. The purpose of the visit was explained. The day program is licensed to serve DEVELOPMENTALLY DISABLE-LEGALLY BLIND CLIENTS AGES 18-59 YEARS. 55 AMBULATORY AND 5 NON-AMBULATORY ONLY. HOURS OF OPERATION 9AM-3PM MONDAY- FRIDAY.

LPA Calderon toured the day program with the Hector Vargas.
* The one story building consists of a production room, workshop room, office room, kitchen area, locker area, 2 restrooms and a maintenance storage room.
* There are no obstructions to the walkways nor any bodies of water.
* The day program does not utilize any sharp knives.
* Hand sanitizers are readily available around the facility and adequate PPE supplies were observed.
* LPA Calderon observed disinfectants, cleaning solutions, under the kitchen sink cabinets unlocked.
* The hot water temperature is measured between 110-degree F, building temperature maintained at 72 F, comfortable for clients in care.
* The fire extinguisher was inspected and fully charged.
* Last Fire Drill conducted 1/4/2023.
* The day program has the smoke/carbon monoxide detectors in each room.
* Clients bring their own food to day program, staff warm up food in microwave/stove, rcfe clients get food from the rcfe facility.
* First Aid kit contains the required items.
* The day program administers medication to certain clients only, kept locked in office room cabinet, LPA reviewed medications along side with Staff Samira Tovar, 5 client medication / medication log book reviewed, no deficiencies noted.
* Day program has a total of (5/6) transportation vehicles.

Deficiency was cited on LIC 809D. Exit interview conducted and a copy of this report and appeal rights were given.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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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Document Has Been Signed on 05/16/2023 03:56 PM - It Cannot Be Edited


Created By: Ashley Calderon On 05/16/2023 at 03:39 PM
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: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) 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 met as evidenced by:
Deficient Practice Statement
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Based on observation and interview , the licensee did not comply with the section cited above, 48 clients present attending day program. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2023
Plan of Correction
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Licensee/ Staff immediately placed disinfectants and cleaning solutions in storage cabniets. Licensee/ Staff will provide LPA with an in-service training on Sec 82087(a)(3) and send documents on locking and having all disnfectants, cleaning solutions, and poisons inaccessible to clients by date May 31, 2023
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023


LIC809 (FAS) - (06/04)
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