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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601257
Report Date: 06/14/2022
Date Signed: 06/14/2022 03:30:46 PM

Document Has Been Signed on 06/14/2022 03:30 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 5FACILITY NUMBER:
198601257
ADMINISTRATOR:SYULLI RUMAGITFACILITY TYPE:
735
ADDRESS:3626 BROOKLINE AVE.TELEPHONE:
(626) 289-5321
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 6CENSUS: 4DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Claudia Uriarte, DSPTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection with the focus of the infection control domain. LPA met with DSP staff and explained the purpose of the visit. The facility is approved for six (6) non-ambulatory developmentally disabled adults, ages 18 - 59. There are currently 4 clients residing at the home.

LPA Chan toured the facility and observed the following:
* There are 5 bedrooms (3 Client bedrooms and 2 vacant rooms designated as isolation rooms), 3 bathrooms, living room, dining area, kitchen, and an attached garage. There are no obstructions to the passageways and no bodies of water.
* The facility has proper Coronavirus (COVID-19) signage at the main entrance and around the home. Hand washing signs are posted in the bathrooms and sink.
* Staff are screening all visitors and documenting their temperature. Staff and clients' temperature are also taken daily and documented.
* Sufficient PPE supplies are stored at the facility.
* The smoke detectors and carbon monoxide detector were tested and operable.
* Food supplies for 2 day perishable and a week of non-perishable were observed.
* Knives and sharps are stored and locked in the kitchen.
* Medications are centrally stored and locked. LPA reviewed all 4 medications and did not observe any deficiencies.
* Per Staff, they are still following the COVID-19 guidance and also clean and disinfect high touched surfaces on every shift.
* The hot water temperature were measured over 120 degrees Fahrenheit in the kitchen sink and bathrooms. The hot water temperature should be maintained between 105-120 degree.

The deficiency is issued on the LIC809D. Exit interview held and a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/14/2022 03:30 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 06/14/2022 at 03:02 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 5
FACILITY NUMBER: 198601257

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088 Furniture, Fixtures, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.
(1) 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).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which the hot water temperature in the kitchen sink measured at 131 and the bathroom sinks at 127.6 which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/15/2022
Plan of Correction
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The Administrator shall adjust the hot water temperature and re-measure the hot water throughout today and tomorrow. The water log shall be submitted to LPA by 6/15/22.
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:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022


LIC809 (FAS) - (06/04)
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