198602053-12-1-2023-28-AS-ACAN-CY4VF2-20231201152313

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602053
Report Date: 12/01/2023
Date Signed: 12/01/2023 03:25:17 PM

Document Has Been Signed on 12/01/2023 03:25 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'S PRIDE		FACILITY NUMBER:	198602053
ADMINISTRATOR:	HECTOR VARGAS		FACILITY TYPE:	740
ADDRESS:	207 WEST CARTER AVENUE		TELEPHONE:	(626) 355-1447
CITY:	SIERRA MADRE	STATE: CA	ZIP CODE:	91024
CAPACITY:	6	CENSUS: 6	DATE:	12/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Wendy Vasquez/ DSP Supervisor		TIME COMPLETED:	01:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA discovered there was no one present. LPA called facility phone number and shortly after Staff member / Medical Coordinator/ Martha Ramos arrived and later Wendy Vasquez/ DSP Supervisor arrived at the facility and assisted with the visit. The facility is licensed to serve six (6) Non-ambulatory Residents ages 60 and over. The facility is vendored with the San Gabriel/ Pomona Regional Center, level RCFE 4C. LPA used CARE Inspection tool to conduct todays visit, a tour of the physical plant was conducted alongside with Martha Ramos, medication was reviewed with Wendy Vasquez, staff and resident file review and staff interviews were conducted. No resident's present during visit therefore no resident interviews were conducted. The facility is located in a residential area. A tour of the single-story facility includes: (3) resident bedrooms, (2.5) resident bathrooms, living room/ office area, dining room, kitchen, laundry room/ pantry, (2) backyards observed and no large body of waters observed. Kitchen and food supply was observed, operable equipment and thermometers in place 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, facility has a pantry with food supplies. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in a secured cabinet and inaccessible to clients. Kitchen Cabinets a total of two drawers are not on track, un-leveled and not sturdy, deficiency noted. There is a functioning telephone and internet on the premises. Continuation 809-C...

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CLIMB'S PRIDE	FACILITY NUMBER: 198602053
	VISIT DATE: 12/01/2023

NARRATIVE

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The bathrooms are clean and operational. Hallway Bathroom were observed water stains / marks , brown and black spots observed on the wall and ceiling and stains and cracks observed on the door casing frame, and paint coming off the wall. Uneven tiles with missing door threshold between the hallway floor and bathroom fall, causing a tripping hazard, deficiency cited.

The hot water temperature was tested throughout the facility and warning sign for water temperature that exceeds over 120F posted above the kitchen sink (used staff only).

-Hallway was observed to have water stain on ceiling and on door casing frame leading to the pantry room, deficiency cited.

-Flooring was observed to have uneven, piling and indented and cracked titles in dining room, living room and in pantry room, deficiency cited.

Residents bedrooms had required furniture, lighting and bed sheets/linen. Room #2 was observed to have ceiling water stains and broken door casing frame, deficiency cited. Resident bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available.

The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. The outdoor activity area is free of visible hazards and debris and the trash cans have covered lids. There are no security bars or weapons on the premises.

All medications for residents are kept locked and inaccessible to other residents. LPA reviewed medication and Medication Administration Record book and found no deficiencies. The first-aid kit is fully stocked w/First-aid Manual. LPA reviewed resident medications.

Administration Certification for Hector Vargas expires: 6/23/2024

Liability Expires:7/15/2025.

Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers were observed to be fully charged and in compliance. Emergency/ Fire Drill Expires: 09/10/2023

Per Title 22 Regulations, deficiency cited, see LIC809-D and TA was given for window/wall cleaning.
An exit interview was conducted and a copy of this report was provided to Wendy Vargas.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/01/2023 03:25 PM - It Cannot Be Edited

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'S PRIDE	FACILITY NUMBER: 198602053
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(2)

Personal Accommodations and Services

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations conducted by LPA alongside with staff, observations were observed of: Hallway Bathroom - water stains / marks , brown and black spots observed on the wall and ceiling and stains and cracks observed on the door casing frame, and paint coming off the wall. Unlevel tiles with missing door threshold between the hallway floor and bathroom fall ,causing a tripping hazard. Hallway- water stain on ceiling and on door casing frame leading to the pantry room. Flooring - uneven, piling and indented and cracked titles in dining room, living room and in pantry room. Room #2- Ceiling water stains and broken door casing frame. Kitchen Cabinets- three drawers are not on track, unleveled and not sturdy. The licensee did not comply with the section cited above in 6 out of 6 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	Administrator will send LPA Calderon images of repairs done on the floor tiles, door threshold, door frames , kitchen cabinets, walls that need cleaning / repair/ paint by POC dur date 12/29/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC809 (FAS) - (06/04)

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