191592837-4-14-2025-28-AS-BPEA-DFQQXQ-20250414123354

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191592837
Report Date: 04/14/2025
Date Signed: 04/14/2025 12:34:26 PM

Document Has Been Signed on 04/14/2025 12:34 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 CENTER		FACILITY NUMBER:	191592837
ADMINISTRATOR/ DIRECTOR:	JANNELLE CANDACE PONCE		FACILITY TYPE:	775
ADDRESS:	161 SIERRA MADRE BLVD		TELEPHONE:	(626) 355-1447
CITY:	SIERRA MADRE	STATE: CA	ZIP CODE:	91024
CAPACITY: 60		CENSUS: 52	DATE:	04/14/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Subash Thankuri - Day Program Asst. Supervisor		TIME VISIT/ INSPECTION COMPLETED:	12:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced required 1-year inspection. LPA Pena met with Subash Thankuri, Day Program Asst. Supervisor and explained the purpose of the visit. The adult day program is licensed to serve developmentally disabled-legally blind clients ages 18-59 years old, approved for (5) non-ambulatory and (55) ambulatory consumers only. Hours of operation are 9am-3pm, Monday-Friday. Services provided by San Gabriel Pomona Regional Center.The current census is (52) consumers. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Facility is a single-story building consisting of (2) activity rooms (workshop and production room), Office, Computer room, 2 bathrooms, kitchen and outdoor covered area. Staff are adhering to infection control requirements. Disinfecting wipes and masks are available in the lobby for consumers and/or visitors use, however there's no hand sanitizers. A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Sufficient space to accommodate both indoor and outdoor activities was observed. Exit doors are free of any obstruction and there are no pools or large bodies of water. There is a drinking station in the facility. There is a shaded rest area with a bench provided for the clients. The facility walls/ floors were in good condition, and there is adequate lighting throughout the facility. The facility has a video camera monitor system in the common areas. Bathrooms were clean, toilets and water faucets worked properly. Hot water temperature was measured and was within the required 105-120 degrees F. Total of (4) fire extinguishers were observed to be fully charged and were last serviced on 04/24/2024. *REPORT CONTINUED ON LIC809-C*

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 04/14/2025

NARRATIVE

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Smoke alarms and carbon monoxide were operable and in compliance.
There are no firearms or weapons stored at the facility.
Fire drills are held every (6) months and the most recent drill took place on 11/05/2024.
The kitchen was inspected. Cleaning solutions, disinfectants and other hazardous items are stored and locked in a cabinet.
Knives and sharps were locked in a cabinet.
The facility serves meals and provides lunch to the consumers.
Surety Bond is in effect with bond amount of $3750.
The first aid kit was stocked and available for use.
This day program administer medications to consumers during lunch only.
The medications are stored in a locked cabinet. Medications were reviewed and are administered as prescribed by the Physician. The facility uses the Medication Administration Record (MAR) log to document medications given.
LPA observed cleaning supplies, disinfecting wipes were stored along with clients medications.

As a part of the inspection, LPA reviewed (5) client records, and (5) staff records. Consumer/staff files are current and in compliance. Staff responsible for direct care and supervision have current First Aid and CPR.

Per California Code of Regulations, Title 22 and Health & Safety Codes, a deficiency was cited during today's visit and a Technical Assistance was issued.

An exit interview was conducted and a copy of this report was provided to Subash Thankuri, Day Program Asst. Supervisor.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/14/2025 12:34 PM - It Cannot Be Edited

Created By: Bennette Pena On 04/14/2025 at 12:13 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: 04/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

82075(l)(1)

Health-Related Services

(l) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, the licensee did not comply with the section cited above in that cleaning supplies and disinfecting wipes were stored along with clients medications which poses an immediate health, safety or personal rights risk to clients in care.
	POC Due Date: 04/15/2025
	Plan of Correction
1 2 3 4	Asst. Program Supervisor immediately removed the cleaning supplies and disinfecting wipes to the proper cabinet that is locked and inaccessible to clients. *DEFICIENCY CLEARED DURING THE VISIT.*

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	David Sicairos
NAME OF LICENSING PROGRAM MANAGER:

	Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025

LIC809 (FAS) - (06/04)

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