198603560-9-18-2023-28-AS-ACAN-CVSUWT-20230918155717

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603560
Report Date: 09/18/2023
Date Signed: 09/18/2023 03:58:43 PM

Document Has Been Signed on 09/18/2023 03:58 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 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: 36	DATE:	09/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator:Hector Vargas		TIME COMPLETED:	04:00 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 required annual inspection. LPA used the CARE Inspection Tool for the purpose of today's visit. Upon arriving at the facility, LPA met with Administrator / Hector Vargas who assisted with the visit. The facility is licensed to serve Residential Care Facility for the Elderly for a capacity of forty (40) residents, ages 60 and over. Licensee prefers to serve Developmentally Disabled Blind Residents. Approved for (5) Hospice Wavier. During today's inspection, the following was observed: LPA toured the inside and outside of the facilities physical plant alongside with Hector Vergas. LPA observed random resident bedrooms: Room 1, Room 14, Room 15 and Room 20. Room #1 was observed and requires repair on the wall near residents closet, wall has chipping and no paint resulting in material in wall (metal) and dry plastered visible. Deficiencies noted. Staff storage room and office were remained closed and inaccessible to residents in care. LPA observed storage room used for chemicals, disinfectants, hygiene supplies and paper goods kept locked and inaccessible to residents. PPE was observed in the Copy Room and facility contains more PPE in storage garage. Facility was kept a comfortable temperature: 74 Degree F. Smoke detectors and pull system observed and hard wired to the Fire Dept. Of Sierra Madre. Carbon Monoxide were tested and operable. Last Fire/ Disaster Drill conducted: 6-28-23. At 11:50AM LPA observed laundry room and laundry room cabinet. Cabinet had a unlocked number pad lock latched but not closed. LPA and Hector observed bleach and laundry detergent in cabinet accessible to clients in care. Hector Vergas immediately closed pad lock shut. Deficiencies were noted. Residents rooms are shared rooms and have required furniture, adequate lights and were kept clean, safe and sanitary. Continuation on 809-C...

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

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 SIERRA MADRE RCFE	FACILITY NUMBER: 198603560
	VISIT DATE: 09/18/2023

NARRATIVE

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LPA observed (2) common restrooms and shower rooms. Shower room #4 had painted chipping on wall, unpainted, painting cracks /paint falling off walls and tiles lifting off wall.
Lounge area observed and dining area observed with posted food menu.
Kitchen area observed: having adequate perishable and non-perishable food items in place for residents in care. Kitchen appliances were operable.
Liability Insurance expires 7/15/2024.
Administrator Certificate expires: 6/3/2024.
Random call systems were tested and were operable.
Outside patio had varies umbrellas and sitting areas for residents in care.
No large bodies of water observed.
Facility number: 626-355-1447, telephones were operable and residents are able to use phones, located in the lounge area.

During today's visit, deficiencies were noted per Title 22 Regulation. An exit interview was conducted and a copy of this report, 809 and appeal rights were given to Administrator Hector Vergas via email do to printer issues.

LPA will return at another time to continue annual inspection. Due to time restraint LPA will return at a further time.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/18/2023 03:58 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 SIERRA MADRE RCFE	FACILITY NUMBER: 198603560
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation/ interview with Admin. Hector Vergas laundry room cabinet was unlocked and accessible to clients in care. The licensee did not comply with the section cited above in 36 out of 36 clients/ persons, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/19/2023
	Plan of Correction
1 2 3 4	Admin.Hector immediately closed pad lock shut during annual inspection. Admin will provide a in-service training regarding regulation 87309 to all staff. In-service training material and sign in sheet will be provided to LPA by 9/29/23.

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: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 09/18/2023 03:58 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 SIERRA MADRE RCFE	FACILITY NUMBER: 198603560
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Calderon and Admin Hector Vargas observations and interview with facility maintenance worker. Resident bedroom #1 bedroom wall near residents closet had wall chipping, no paint, visible material in wall (metal) and dry plastered visible, repairs required. Common shower #4 has tile lifting off wall, unpainted, wall painting cracks and lifted paint. The licensee did not comply with the section cited above in 36 out of 36 residents/persons,which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2023
	Plan of Correction
1 2 3 4	Administrator will contact Maintenance worker and provide in voice paperwork or email regarding scheduled repairs on what is needed and what will be fixed and/or reciepts if appliaciable . Admin. will send docuemantion to LPA Calderon and picture repairs of room #1 and shower #4 by POC 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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

LIC809 (FAS) - (06/04)

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