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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601105
Report Date: 09/30/2021
Date Signed: 09/30/2021 11:33:20 AM

Document Has Been Signed on 09/30/2021 11:33 AM - 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 3FACILITY NUMBER:
198601105
ADMINISTRATOR:ANNETTE KYAMPAIREFACILITY TYPE:
735
ADDRESS:315 SOUTH RUSSELL AVENUETELEPHONE:
(626) 289-5321
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY: 4CENSUS: 4DATE:
09/30/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Annette Kyampaire, AdministratorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Cynthia Chan made an announced case management visit for the purpose of a capacity increase from four (4) non-ambulatory to six (6) non-ambulatory clients. LPA met with Administrator Annette Kyampaire. The fire clearance was approved by the local Fire Inspector on 9/7/21.

LPA toured the facility with the Administrator. The facility has a total of 5 bedrooms and 4 bathrooms, which were observed to be clean and in good condition. The 5th room located right before the back living room, was converted into bedroom #5. Bedroom #5 is set up as a shared client bedroom for 2 non-ambulatory clients. This client bedroom consists of 2 beds in good repair, 2 chairs, 2 night stands with a lamp on each, and 2 drawers. The hot water temperature was measured and maintained between 105 - 120 degrees F. There are sufficient supplies of perishable and non-perishable food observed. LPA also observed extra linens, hygiene supplies, dinnerware, and silverware to accommodate up to 6 clients.

There are no deficiencies observed during today's visit. An exit interview was conducted and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
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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