<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600949
Report Date: 06/04/2024
Date Signed: 06/05/2024 01:50:26 PM

Document Has Been Signed on 06/05/2024 01:50 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/
DIRECTOR:		NGUYEN, JOHNFACILITY TYPE:
735
ADDRESS:1317 SOUTH GLADYS AVENUETELEPHONE:
(626) 571-2363
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY: 6CENSUS: 4DATE:
06/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:John Nguyen, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:55 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
***This amended report was created to correct the Administrator name on the report. On 6/4/2024, Licensing Program Analyst (LPA) Noemi Galarza made an unannounced annual inspection visit. The purpose of the visit was explained to DSP Eric Hanson. Administrator John Nguyen arrived shortly after. The facility is a Specialized level 4b Adult Residential Facility (ARF) that serves developmentally disabled residents ages 59 and under vendored by Eastern Los Angeles Regional Center. The home consists of a two-story home licensed for 6 non- ambulatory residents. 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 following 12 (CARE) tool domains were utilized during the inspection.

Infection Control: Facility staff are no longer screening visitors. Hand hygiene and disinfectant cleaning protocols are in place. An Infection Control Plan was reviewed.

Physical Plant/Environment Safety: 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 were tested and are operation. The facility has two (2) fully charged fire extinguishers. Hot water temperature readings measured between the required 105 - 120 degrees Fahrenheit. The facility is equipped with a sprinkler system. The last fire inspection was conducted on 7/6/2023 by San Marino Security Systems Inc.

Resident (R1 & R2's) room walls/baseboards, upstairs bathroom faucet and kitchen faucet, and entrance baseboard are in disrepair.

Storage areas for cleaning solutions/toxins, knives, and hazardous items were inaccessible to clients; with the exception of 1 kitchen cabinet that contained a pair of scissors that were unlocked.

Operational Requirements: The Program Design was reviewed. Fire clearance is 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 residents. Facility manages residents P & I monies. The Surety Bond was effective 2/28/2024.


Staffing: A total of 10 staff members provide care and supervision to the clients.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2024
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 5
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: 06/04/2024
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
26
27
28
29
30
31
32
Personnel Records/Staff Training: Four (4) staff files were reviewed and contained criminal background clearance, in-service training, 1st Aid/CPR training, CPI training, and health screening. Staff (S1) has expired CPI training and staff (S4) does not have CPI training on staff record.

Administrator certificate expires 10/1/2024.

Resident Rights/Information: Resident Personal Rights poster is posted in the common area. Internet access is available for clients. Physician's orders are on file.

Resident Records/Incident Reports: Four (4) resident files were reviewed containing admission agreements, Physician's Reports, IPPs, medical/functional assessments, Behavior Reports, TB clearance, personal rights, medical consent, medication records, and P & I bank records.

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.

Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Medications 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 residents have a Needs and Services Plan and updated medical assessments.

Disaster Preparedness, and Emergency Intervention: A current LIC 610D updated form "Emergency Disaster Plan/Disaster and Mass Casualty Plan was reviewed.

The last Fire/Emergency Drill was conducted on 5/1/2024.

Emergency Intervention: No manual restraints, seclusion, or de-escalation techniques are used.

Per Title 22, California Code of Regulations, a deficiencies were cited.



Exit interview with Administrator was conducted. A copy of the report/appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/04/2024 04:54 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/04/2024 at 04:38 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, INC. ARF#1
FACILITY NUMBER: 198600949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that scissors were found unlocked in a kitchen cabinet, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2024
Plan of Correction
1
2
3
4
Administrator agreed to submit a written POC and proof of staff training.
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.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/04/2024 04:54 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/04/2024 at 04:38 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, INC. ARF#1
FACILITY NUMBER: 198600949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on osbervation, the licensee did not comply with the section cited above in that resident (R1 & R2's) room has walls and baseboard are damaged, upstairs bathroom faucet and kitchen faucet need repair, and front entrance baseboard was chipped/damaged, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2024
Plan of Correction
1
2
3
4
Administrator shall submit picture proof of repairs completed in the resident rooms, front entrance, and faucets.
Type B
Section Cited
CCR
85165(h)(1)
Emergency Intervention Staff Training
(h) The licensee shall maintain a written record of the staff training. (1) Documentation of the training received by each staff member shall be maintained in the personnel records, pursuant to Section 80066, and include:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that staff (S1) has expired CPI training and staff (S4) has no CPI training on record, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2024
Plan of Correction
1
2
3
4
Administrator agreed to submit proof that S1 & S4 have current CPI training..
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5