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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601105
Report Date: 05/10/2022
Date Signed: 05/10/2022 05:19:22 PM

Document Has Been Signed on 05/10/2022 05:19 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 3FACILITY NUMBER:
198601105
ADMINISTRATOR:ANNETTE KYAMPAIREFACILITY TYPE:
735
ADDRESS:315 SOUTH RUSSELL AVENUETELEPHONE:
(626) 289-5321
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY: 6CENSUS: 4DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Annette Kyampaire, AdministratorTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the Infection Control domain. LPA met with the Administrator, Annette Kyampaire, who assisted with the inspection. The facility is licensed to serve six (6) developmentally disabled adults ages 18 - 59 and approved for 6 non-ambulatory clients. There are currently 4 clients residing at the home and are placed by the Eastern Los Angeles Regional Center. The facility has an approved mitigation plan.

LPA toured the facility with the Administrator and observed the following:
* The facility has 5 bedrooms, 4 bathrooms, living/dining room, kitchen, laundry room, storage room, second living room, and a detached garage. The facility is well maintained with no items obstructing the passageways. LPA observed signage throughout the facility and in the restrooms for hand washing hygiene. PPE supplies for at least 30 days are observed. Food supplies for 2 day perishable and a week of non-perishable are also observed. Knives, cleaning solutions, and disinfectants are stored and locked making them inaccessible to clients. Smoke detectors and a carbon monoxide detector were tested and operable. The fire extinguishers were last inspected on 4/6/22. Medications are centrally stored and locked in the kitchen cabinet. LPA reviewed all 4 clients' medications and staff are administering them as prescribed.
LPA provided a technical advisory for the N95 Respirator Fit Testing.

No deficiencies were observed during the visit today. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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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