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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603560
Report Date: 09/20/2023
Date Signed: 09/20/2023 01:17:55 PM

Document Has Been Signed on 09/20/2023 01:17 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 RCFEFACILITY NUMBER:
198603560
ADMINISTRATOR:VARGAS, HECTORFACILITY TYPE:
740
ADDRESS:161 W. SIERRA MADRE BLVD.TELEPHONE:
(626) 289-5321
CITY:SIERRA MADRESTATE: CAZIP CODE:
91024
CAPACITY: 40CENSUS: 36DATE:
09/20/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator:Hector VargasTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced annual continuation case management visit. LPA continued to use 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 alongside with Medical Coordinator Patrcia Mancillas-Wong, reviewed (3) resident medications and M.A.R.S.
  • LPA alongside with Hector Vargas tested hot water in common restroom #2, resident bedroom #2 and resident bedroom #5 which tested within Title 22 regulations.
  • LPA reviewed (5) staff and (5) residents files, all files had proper documentation's and TB. Staff are cleared and have current First Aid/CPR certification.
  • LPA observed fully equipped first aid and a current manual book.
  • LPA observed certain residents beds with postural support bed side railing, LPA reviewed physician orders in place for resident(s) in Room #2, Room #7, Room #9 and Room #20.

No deficiencies cited on today's visit. Exit Interview conducted with Administrator Hector Vargas and copy of report will be provided to Vargas email, due to printer issues.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2023
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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