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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601246
Report Date: 08/27/2021
Date Signed: 08/27/2021 02:47:50 PM

Document Has Been Signed on 08/27/2021 02:47 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 4FACILITY NUMBER:
198601246
ADMINISTRATOR:ANNETTE KYAMPAIREFACILITY TYPE:
735
ADDRESS:2315 S. STRANAHAN DRTELEPHONE:
(626) 281-8441
CITY:ALHAMBRASTATE: CAZIP CODE:
91803
CAPACITY: 4CENSUS: 4DATE:
08/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Staff / Evelyn Brindis
Covering Administrator / Estrella Delmmundo		TIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility, there was no one present. LPA contacted the Business Office and spoke with Sheryl Barnardo and Ms. Barnardo sent staff to meet LPA at the facility. A short time after LPA met with Staff / Evelyn Brindis and Covering Administrator / Estrella Delmmundo who assisted with the visit. The facility is licensed to serve four (4) Developmentally Disabled adults ages 18 through 59 years old. Approved for four (4) Non-Ambulatory clients. During today's visit, LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies reviewed.

The facility is located in a residential area. A tour of the single-story facility includes: A living room, dining room, kitchen, laundry room, 4 client bedrooms, 2 restrooms, an attached garage and indoor/outdoor activity areas. All medications for clients who need assistance are kept locked and inaccessible to other clients. Knives, disinfectants and cleaning solutions are kept locked and inaccessible to clients. The bathrooms are clean and operational. Client bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The hot water temperature was tested throughout the facility. 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. LPA reviewed client medications.

Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was located in the kitchen and was observed to be fully charged and in compliance. The first-aid kit is fully stocked w/First-aid Manual. The front yard is well landscaped with steps that leads to the entry. A shaded area with chairs is provided in the back yard. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. The trash cans have covered lids. There is no evidence of bodies of water (pool) or security bars nor weapons on the premises. The attached garage is kept locked and inaccessible to clients at all times.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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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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 4
FACILITY NUMBER: 198601246
VISIT DATE: 08/27/2021
NARRATIVE
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During today's visit, the following concerns were observed;
  • At 10:09AM, the hot water temperature in the kitchen was measured at 126.1 degrees F. At 10:15AM, the hot water temperature in the main bathroom was measured at 128.1 degrees F. At 10:21AM, the hot water temperature in bedroom #3 was measured at 126.4 degrees F.
  • At 10:38AM, while reviewing the medications for Client #1 (C1), LPA discovered that staff initials were missing for Milk of Magnesia (Take 1 tablespoon full by mouth 2 times daily for constipation) on the Medication Administration Record (MAR) for the PM dose under dates 8/24/21 - 8/26/21. It is unknown if the Milk of Magnesia was administered to C1 per physician's orders.


The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted and a copy of this report was provided along with the Appeals Rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2021 02:47 PM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 08/27/2021 at 12:12 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 4
FACILITY NUMBER: 198601246

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/27/2021
Section Cited

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Furniture, Fixtures, Equipment, and Supplies.
Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
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This requirement was not met as evidenced by; At 10:09AM, the hot water temperature in the kitchen was measured at 126.1 degrees F. At 10:15AM, the hot water temperature in the main bathroom was measured at 128.1 degrees F. At 10:21AM, the hot water temperature in bedroom #3 was measured at 126.4 degrees F.
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Type A
08/30/2021
Section Cited

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Health Related Services. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.


This requirement was not met as evidenced by;
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At 10:38AM, while reviewing the medications for C1, LPA discovered that staff initials were missing for Milk of Magnesia (Take 1 tablespoon full by mouth 2 times daily for constipation) on the MAR for the PM dose under dates 8/24/21 - 8/26/21. It is unknown if the Milk of Magnesia was administered to C1 per physician's orders.
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2021


LIC809 (FAS) - (06/04)
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