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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600949
Report Date: 06/22/2023
Date Signed: 06/22/2023 04:21:43 PM

Document Has Been Signed on 06/22/2023 04:21 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, INC. ARF#1FACILITY NUMBER:
198600949
ADMINISTRATOR:NGUYEN, JOHNFACILITY TYPE:
735
ADDRESS:1317 SOUTH GLADYS AVENUETELEPHONE:
(626) 571-2363
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY: 6CENSUS: 4DATE:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:John Nguyen, AdministratorTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Administrator John Nguyen. Substitute Administrator Annette Kyampaire. There are four (4) ambulatory developmentally disabled adults ages 18-59. The facility is licensed as a level 4b Specialized home vendored by Eastern Los Angeles Regional Center.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still requires masks and encourages hand washing and self symptom check of staff and visitors. Each resident bedroom is designated as a COVID-19 isolation room if needed. The facility has an Infection Control Plan and COVID-19 mitigation plan.
Physical Plant/Environment Safety:
  • Facility is a two-story home licensed for 6 non- ambulatory clients. It is located in a residential area consisting of five (5) client bedrooms, (1) staff rooms, 3 bathrooms, kitchen, dining room, laundry room, living room, family room, patio area, and attached garage. The facility is equipped with a sprinkler system. The last fire inspection was conducted on 5/26/2022 by San Marino Security Systems Inc.

  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has one (1) fully charged fire extinguisher. Cleaning supplies and toxic substances are inaccessible to clients.

  • Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
See next page
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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, INC. ARF#1
FACILITY NUMBER: 198600949
VISIT DATE: 06/22/2023
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Operational Requirements:
  • The Program Design is current.
  • Fire clearance has been approved for six (6) non- ambulatory residents.
  • Care and supervision to meet the clients needs was observed. No special equipment and supplies are used by clients.
  • Surety bond was reviewed and is current.

Staffing:
  • A total of eight (8) staff members provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificate expires 10/1/2024.
  • Four (4) staff files were reviewed for criminal background clearance and training.
  • Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.

Client Rights/Information:
  • Physician orders, and personal rights were reviewed in client files.

Client Records/Incident Reports:
  • Four (4) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, and medication administration records. Personal & Incidental (P & I) monies/records are centralized in corporate office.

Food Service:
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
  • There are no physician orders for modified diets.

See next page.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
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, INC. ARF#1
FACILITY NUMBER: 198600949
VISIT DATE: 06/22/2023
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Health Related Services:
  • Clients are assisted with self administration of prescription and non-prescription medications.
  • Two (2) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions. 30-Day supply of medications were observed.

Incident Medical and Dental:
  • All clients have a Needs and Services Plan and COVID-19 vaccination cards on file.
  • Staff training was on file.

Disaster Preparedness, and Emergency Intervention:
  • A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed.
  • An emergency drill was conducted on 5/3/2023.


Emergency Intervention:
  • No manual restraints or seclusion are used with clients in care.

No deficiencies were cited.

Exit interview conducted with Administrator John Nguyen. A copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3