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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592837
Report Date: 05/02/2024
Date Signed: 05/02/2024 12:08:46 PM

Document Has Been Signed on 05/02/2024 12:08 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CLIMB WORK ACTIVITY CENTERFACILITY NUMBER:
191592837
ADMINISTRATOR/
DIRECTOR:		JANNELLE CANDACE PONCEFACILITY TYPE:
775
ADDRESS:161 SIERRA MADRE BLVDTELEPHONE:
(626) 355-1447
CITY:SIERRA MADRESTATE: CAZIP CODE:
91024
CAPACITY: 60CENSUS: 51DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:12 AM
MET WITH:Jannelle Ponce - Day Program ManagerTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA's) Tena Herrera and Daniel Konishi, conducted an unannounced visit for an Annual Inspection. Upon arrival, LPA met with Patricia Wong (Medical Coordinator at independent living next door) who led LPA's to Day Program, LPA's were introduced to Day Program Manager Janelle Ponce who assisted with todays visit and LPA's explained the purpose for the visit. The facility is licensed to serve 60 Adults (55 Ambulatory and 5 Non-Ambulatory) ages 18 to 59 years old.

This is a single- story facility located in Sierra Madre, Ca. A tour of the facility includes: 2 large activity rooms, a quiet/computer room, 2 client restrooms and a kitchen.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: The facility staff are using appropriate hand hygiene and cleaning/disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.
Physical Plant & Environment Safety: Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers were observed and are fully charged. No bodies of water were observed at the facility. The hot water temperature was tested throughout the facility restrooms and measured within the required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, poisons and hazardous items are stored in a secured/locked storage closet and inaccessible to clients. There is a shaded rest area provided for the clients(due to recent winds canopy is stored away, LPA verified facility does have supplies for an outdoor shaded area). Clients are provided with a non-contaminating water container that is readily available for indoor and outdoor use. The facility appears to be clean safe and sanitary.

(Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CLIMB WORK ACTIVITY CENTER
FACILITY NUMBER: 191592837
VISIT DATE: 05/02/2024
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Operational Requirements: The facility has the appropriate fire clearance. Staff are knowledgeable on their reporting requirements.
Staffing: There appears to be sufficient staffing at all times in the facility. There are at least 2 staff members on duty any time there are clients in the facility. The staff to client ratio is 1 caregiver to 3 consumers.
Personnel Records-Training: Staff files were readily available during visit. LPA reviewed 6 staff files, each file reviewed have criminal record clearance, current First Aid/CPR and sufficient on-going training. Administrator Hector Vargas certificate expires on 6/03/24.
Client Records-Incident Reports: Client files are kept in a secure location within the staff office and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Consent Forms, and Appraisal Needs & Services Plan. LPA reviewed 5 client records without any issues.
Client Rights-Information: Client Rights Poster is posted within the kitchen. Per staff interviews conducted, staff were able to provide multiple types of client rights.
Food Service: Pesticides and other similar toxic substances are not stored in food storerooms or other kitchen areas.
Health Related Services: Staff responsible for providing direct care and supervision maintain training in First Aid and CPR.
Incidental Medical & Dental: Staff have proper training and training is documented within the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and relocation sites. Facility did not have proof of fire drills during todays visit, details will be cited on the 809-D.
Emergency Intervention: Clients at this facility have not needed the use of restraints or the use de-escalation techniques.

LPA Konishi conducted 5 staff interviews and 5 client interviews during today’s visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiency observed during today’s visit is documented on the 809-D.

Exit interview was held and a copy of the report was provided to Janelle Ponce.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
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Document Has Been Signed on 05/02/2024 12:08 PM - It Cannot Be Edited


Created By: Tena Herrera On 05/02/2024 at 11:49 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: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82023(d)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review and converstation with Day Program Manager, the licensee did not comply with the section cited above as when asked for fire drill log Manager stated they dont know where they are or when the last drill was conducted, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2024
Plan of Correction
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Day Program Manager Janelle Ponce to ensure that Fire Drill will be conducted and a copy of Log will be emailed to LPA by POC due date, Log will inculde date/time and paticipants present during drill.
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
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