198602053-11-22-2024-28-AS-BPEA-DB9SQ3-20241122130405

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602053
Report Date: 11/22/2024
Date Signed: 11/22/2024 01:04:23 PM

Document Has Been Signed on 11/22/2024 01:04 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'S PRIDE		FACILITY NUMBER:	198602053
ADMINISTRATOR/ DIRECTOR:	HECTOR VARGAS		FACILITY TYPE:	740
ADDRESS:	207 WEST CARTER AVENUE		TELEPHONE:	(626) 355-1447
CITY:	SIERRA MADRE	STATE: CA	ZIP CODE:	91024
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	11/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:34 AM
MET WITH:	Wendy Vasquez - DSP Supervisor Hector Vargas - Administrator Marta Ramos - Asst. Wellness Director		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit. LPA arrived at the facility and rang the doorbell, but no one answered. LPA called the facility and spoke with Patricia Wong who contacted another staff who will be coming to the facility to assist. At 10:04am, Marta Ramos, Asst. Wellness Coordinator arrived but had the wrong keys and could not open the door. At 10:20am, Wendy Vasquez, DSP Supervisor arrived to let LPA in and explained the purpose of the visit. At 10:45am, Hector Vargas arrived and assisted with the inspection. The facility is licensed to care for (6) non ambulatory residents age 60 and over. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Bathroom has hygiene items such as paper towel, hand soap and toilet paper.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is in place. Liability Insurance policy is valid and will expire on 07/15/2025. Surety Bond Insurance with bond amount of $3750 is valid and will expire on 02/28/2025. Last Fire Drill was conducted on 10/22/2024 and according to the Administrator, emergency drills are conducted on a quarterly basis.

Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood which consists of (3) resident bedrooms, (3) bathrooms, living room with fireplace, kitchen, dining area, laundry/storage area, side yard and backyard. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. LPA observed that the coating on the bathtub in bathroom #1 was chipping and worn out. Side yard and backyard were inspected and have a shaded and sitting area. There are (2) fire extinguishers in the facility which was last serviced on 04/24/2024. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature reading measured within the required 105 - 120 degrees Fahrenheit. Water readings were 112.2 deg. F in bathroom #1, 109.5 deg F in bathroom #2 and 110.6 deg F in bathroom #3.

*****REPORT CONTINUED ON LIC809-C*****

David Sicairos	TELEPHONE: (323) 981-3982
Bennette Pena	TELEPHONE: (323) 981-3307
	DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

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'S PRIDE	FACILITY NUMBER: 198602053
	VISIT DATE: 11/22/2024

NARRATIVE

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Staffing: A total of nine (9) staff members including the Administrator provide care and supervision to the client. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, and associated to the facility.

Personnel Records/Staff Training: Staff files are maintained at the facility. LPA reviewed (3) staff files. Administrator's proof of health clearance, fingerprint clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate expired on 06/23/2024, but sent renewal to CDSS on 05/13/2024.

Resident Rights-Information: Facility provides internet services to all residents and have access to the facility phone.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed.

Food Service: There is sufficient food supplies of 2-day perishable and 7-day supplies of non-perishable items. The food is properly stored in the refrigerator. There are no residents with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen was inspected and the milk stored in the refrigerator expired on Nov. 17. Kitchen is kept clean and free from rodents and other vermin.

Resident Records-Incident Reports: LPA reviewed (3) resident files. Resident files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Special Incident Reports, PNI, Resident Personal Property and Personal Rights observed.

Health Related Services: The medications are centrally stored and in their original containers and bubble packed. LPA reviewed medication for (6) residents. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. First-aid supplies along with a manual are maintained in the facility.

Incidental Medical Services: There are no residents in the facility with incidental medical services nor have a restricted health condition.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.

Emergency Intervention: Not-Applicable.

Deficiencies cited. Exit interview and a copy of this report was provided to the Administrator, Hector Vargas.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 11/22/2024 01:04 PM - It Cannot Be Edited

Created By: Bennette Pena On 11/22/2024 at 12:19 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'S PRIDE	FACILITY NUMBER: 198602053
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(a)

General Food Service Requirements

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Administrator did not comply with the section cited above in that the gallon of milk stored in the refrigerator expired on Nov. 17 which poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 11/22/2024
	Plan of Correction
1 2 3 4	Deficiency cleared during visit, DSP Supervisor threw the expired gallon of milk from the refrigerator.

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:

David Sicairos

TELEPHONE: (323) 981-3982

LICENSING EVALUATOR NAME:

Bennette Pena

TELEPHONE: (323) 981-3307

LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 11/22/2024 01:04 PM - It Cannot Be Edited

Created By: Bennette Pena On 11/22/2024 at 12:19 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'S PRIDE	FACILITY NUMBER: 198602053
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(6)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Administrator did not comply with the section cited above in that the coating on the bathtub in bathroom #1 was chipping and worn out which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 12/04/2024
	Plan of Correction
1 2 3 4	Administrator agreed to have the bathtub recoated or refinished and will send proof/pictures to CCL/LPA by POC due date.

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:

David Sicairos

TELEPHONE: (323) 981-3982

LICENSING EVALUATOR NAME:

Bennette Pena

TELEPHONE: (323) 981-3307

LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

LIC809 (FAS) - (06/04)

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