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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601105
Report Date: 04/11/2024
Date Signed: 04/11/2024 05:18:02 PM

Document Has Been Signed on 04/11/2024 05:18 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/
DIRECTOR:		ANNETTE KYAMPAIREFACILITY TYPE:
735
ADDRESS:315 SOUTH RUSSELL AVENUETELEPHONE:
(626) 289-5321
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY: 6CENSUS: 4DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:39 PM
MET WITH:Annette Kyampire, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:26 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA was greeted by DSP Blanca Cuellar and Annette Kyampire, Administrator, arrived a short time later and assisted with the visit. LPA explained the purpose of the visit.

The facility is licensed to serve 6 ambulatory and developmentally disabled clients aged 18 to 59. Currently, there are four (4) clients in placement. Three clients are over 60 years of age. All clients are provided Case Management services by East Los Angeles Regional center.

Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves.
while assisting clients. Staff are disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Bathrooms have hand washing signs, soap and paper towels. Per Facility Administrator all staff also have the COVID-19 vaccines including boosters. Facility Administrator is adhering to infection control requirements.

Operational Requirements: Fire Drills are conducted every 6 months; the last fire drill was conducted on 2/17/2024 Emergency Disaster/ Earthquake Drills are conducted every 6 months and the last one was conducted on 02/17/2024. LPA advised to conduct drill quarterly.

LIC 809C for continuation of report.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 04/11/2024 05:18 PM - It Cannot Be Edited


Created By: Alberto Lopez On 04/11/2024 at 05:00 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 3
FACILITY NUMBER: 198601105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(e)
Acceptance and Retention Limitations
(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. # clients over 60 did not have an updated medical assessments in Residential Care Facilities for the Elderly (RCFE) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
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Administrator will update medical assessments in Residential Care Facilities for the Elderly (RCFE) for 3 clients over 60 years of age and send proof to LPA by POC.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024


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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: 04/11/2024
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Physical Plant & Environment Safety:

Facility consists of living room, staff space, kitchen, dining room, 5 client bedrooms, 1 shared, 4 client bathrooms, detached garage, and enclosed backyard. and indoor/outdoor activity areas. LPA observed appropriate furniture, lighting fixtures, personal storage space as required, Beds have adequate amount of linen and mattresses, and box springs are in good repair. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. Bathroom sinks and showers were free of mold/mildew. LPA observed that sufficient toiletries accessible to clients. Water temperature measured between 113.1- 116.6 degrees which is within range of 105.0 – 120 Degrees F. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. First aid kit is fully stocked with manual, smoke alarms and carbon monoxide detectors were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Fire extinguisher(s) are fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. Exits were marked with signs. Notifications and postings were observed which included personal rights, visitor policy, complaint procedures, menu, and emergency disaster plan.




Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18, are fingerprint and cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, and S1-S3. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting. Administrator RCFE Certificate expires 01/26/2025. Renewal for ARF certificate is pending.

Client Rights-Information: Client personal rights and House Rules are posted. Per Facility Administrator, facility provides wi-fi services for facility clients.


SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
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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: 04/11/2024
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Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Consent for Medical Treatment, Appraisal Needs and Services Plan, Functional Capabilities Assessment, Mental Health Intake Assessment, Client Cash Resources. Special Incident Reports, Client Personal Property and Clients Personal Rights. Physician's Report for the Elderly LIC602 (including T.B and Ambulatory Status), is missing for 3 clients over 60

Food Service: The facility has sufficient food supplies of 2-day perishable and 7 day supply of non-perishable items. The food is properly stored in the refrigerator which is clean and well maintained. There are no clients with special diets residing at this facility. Kitchen is kept clean and free from rodents and other bugs/insects. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for 4 clients. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly. PRN letters are missing for 2 clients.

Incidental Medical Services: Per Facility Administrator, there are no clients at this home with incidental medical services or restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster Plan but needs to be updated after staff is trained.

Emergency Intervention: Not Applicable.

Deficiency noted. Technique advisories provided. Exit interview and a copy of this report, 809D and appeal rights was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
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