198603560-7-13-2022-28-AS-JKAN-CG9U9J-20220712152312

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603560
Report Date: 07/12/2022
Date Signed: 07/13/2022 07:26:48 AM

Document Has Been Signed on 07/13/2022 07:26 AM - 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 SIERRA MADRE RCFE		FACILITY NUMBER:	198603560
ADMINISTRATOR:	VARGAS, HECTOR		FACILITY TYPE:	740
ADDRESS:	161 W. SIERRA MADRE BLVD.		TELEPHONE:	(626) 289-5321
CITY:	SIERRA MADRE	STATE: CA	ZIP CODE:	91024
CAPACITY: 40		CENSUS: 38	DATE:	07/12/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Executive Director / Hector Vargas Director of Operations / Alexis Boxer		TIME COMPLETED:	02:30 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 Analysts (LPAs) Joe Katrdzhyan and YaTing Yang conducted an announced pre-licensing visit. LPAs met with Executive Director / Hector Vargas and Director of Operations / Alexis Boxer for the purpose of conducting a pre-licensing inspection. Licensee / Climb Inc., has submitted an application to operate a Residential Care Facility for the Elderly for a capacity of forty (40) residents, ages 60 and over. The facility has an approved fire clearance for thirty (30) ambulatory residents and ten (10) non-ambulatory residents only. Fire clearance was granted on 7/1/22. The new application is being processed as a change of facility type. There are currently thirty-eight (38) residents living at the facility. Licensee prefers to serve Developmentally Disabled Blind Residents. Climb Sierra Madre RCFE does not have an approved Dementia Care Plan in their plan of operation and will NOT be accepting or caring for residents with dementia. LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is located in a commercial neighborhood. The facility consists of a main floor. A tour of the main floor includes twenty (20) resident rooms, a living room/activity room, dining room, kitchen, three (3) separate shower rooms, one (1) separate tub room, two (2) common bathrooms, medication room, laundry room, multiple storage rooms, patio and indoor/outdoor activity areas. Some resident rooms have their own bathrooms, some resident rooms have shared bathrooms and some resident rooms have no bathrooms. LPAs observed a fully equipped living room and a dining room with sufficient dining capacity. Resident bedrooms were inspected for linens and personal accommodations for safety, privacy, and comfort. Resident bedrooms were equipped with a bed, chair, night stand, adequate lighting and ample closet/storage space for each resident. The bathrooms are clean and operational with non-skid mats. The kitchen was observed for the ability to prepare and serve food. Appliances in the kitchen were clean and all appeared functional. The supply of dishes/cups is adequate. Meals for residents (breakfast, lunch and dinner) are catered from Morrison Community Living seven days a week. Deliveries are made once in the morning (for breakfast) and

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

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 3

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 SIERRA MADRE RCFE	FACILITY NUMBER: 198603560
	VISIT DATE: 07/12/2022

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
26
27
28
29
30
31
32

once in the afternoon (for lunch and dinner). This may change in the future as facility will be renovating the kitchen so that all meals are prepared and served at the facility. During today's visit, LPAs observed an appropriate food supply of two days of perishables and seven (7) days of non-perishables.

LPAs observed a total of five (5) pull-switch fire alarms throughout the facility (one located by the front door/main entrance, one located by the side entrance, one located across from room #24, one located by the rear exit door and one located in the kitchen). The facility is equipped with a centralized sprinkler system. The facility has a central heating system and individual AC units inside resident bedroom.

Medications and First Aid Kit will be centrally stored and locked in the medication room, located near the living room/activity room area. First aid kit is fully stocked with a manual. Resident and staff records are centrally stored and locked in the Executive Director's office, which is located in a separate building behind the facility. Residents P&I monies are centrally stored and locked in the business office, which is also located in the back building. All sharp objects and knives are stored in the kitchen cabinet making it inaccessible to residents. Cleaning supplies are locked in the storage room, making it inaccessible to residents. No firearms will be kept at the facility. The facility smoke detectors are hard wired. Carbon monoxide detectors were observed throughout the facility. The fire extinguishers were fully charged and in compliance. There is a functioning telephone on the premises. The hot water temperature was tested throughout the facility. All toxins such as cleaning solutions and detergent soap are also locked in the storage room. There is no pool or other bodies of water.

LPA observed the Emergency Disaster Plan, Personal Rights and Facility Sketch posted inside the facility as mandated by Title 22 Regulations.

The following concerns were observed during today's visit;

The hot water temperature was tested throughout the facility and did not meet California Code of Regulations Title 22, in the following rooms; The hot water temperature in room #12 was measured at 124.6 degrees F. The hot water temperature in room #24 was measured at 123.5 degrees F. The hot water temperature in room #40 was measured at 132 degrees F. The Executive Director will ensure that the hot water temperature is maintained between 105 degrees F - 120 degrees F throughout the facility as required and submit a log for the next 24 hours showing the actual reading in rooms #12, #24 and #40.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 SIERRA MADRE RCFE	FACILITY NUMBER: 198603560
	VISIT DATE: 07/12/2022

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
26
27
28
29
30
31
32

During a walk through of the facility, LPA observed that the facility was not equipped with a signal system. Title 22 Regulations Section 87303 / Maintenance and Operation states;

(i) Facilities shall have signal systems which shall meet the following criteria:

(1) All facilities licensed for 16 or more and all residential facilities having separate floors or

buildings shall have a signal system which shall:

(A) Operate from each resident's living unit.

(B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory

signal at the living unit loud enough to summon staff.

Prior to licensure, the Licensee shall ensure that the facility is in compliance with California Code of Regulations Title 22, Section 87303 / Maintenance and Operation and submit proof of correction to CCL

During today's visit, LPA reminded the Executive Director that prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption.

Component III was conducted during this visit.
LPA used the inspection tool and the pre-licensing checklist for a Residential Care Facility for the Elderly during this visit.

An exit interview was conducted and a copy of this report was provided to the Executive Director.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3