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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601105
Report Date: 06/01/2023
Date Signed: 06/01/2023 12:43:45 PM

Document Has Been Signed on 06/01/2023 12:43 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, 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:
06/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Annette Kyampaire - AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with John Nguyen (Administrator at another location) who assisted with the visit and later with the Administrator Annettte Kyampaire. The facility is licensed to serve 6 developmentally disabled clients ages 18 to 59 years old.

The facility is a single-story home located in a residential. A tour of the facility includes: living room / dining area, kitchen, 5 client bedrooms, 1 storage closet, 4 bathrooms, laundry room, den, detached garage, front yard, and backyard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan posted by the entrance.


Physical Plant & Environment Safety: There are 5 client bedrooms, 1 storage closet, 3 client bathrooms, 1 staff bathroom, living room / dining area, kitchen, detached garage, front yard, and backyard. All bathrooms are clean and operational. Clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested in all 4 bathrooms and measured between 107.4 – 117.8 degrees F which are within the required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in a secured cabinet and inaccessible to clients. The last Fire/Emergency Drill was conducted on 04/15/23. Smoke detectors and carbon monoxide detectors are operable and in compliance. There were 2 fire extinguishers observed and both are fully charged.
(Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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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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, INC. ARF 3
FACILITY NUMBER: 198601105
VISIT DATE: 06/01/2023
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Operational Requirements: There are currently 4 non-ambulatory residents residing at the facility.
Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Annette Kyampaire certificate expires on 1/26/25.
Personnel Records-Training: Staff has criminal record clearance, current first aid, CPR, and sufficient on-going training. . Staff files are maintained at the facility in a locked file closet.
Client Rights-Information: Client personal rights poster is posted in the hallway.
Client Records-Incident Reports: Client files are kept locked in a file closet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report (on tablet with other electronic files), Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication has the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. During the visit today, LPA reviewed all 4 clients’ medication no issues were observed.
Incidental Medical & Dental: All medications for clients are kept locked and inaccessible.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.

LPA conducted 2 staff interviews and 0 client interviews as clients were away at day program.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit.

Exit interview held and a copy of the report was provided to Administrator Annette Kyampaire.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC809 (FAS) - (06/04)
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