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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603560
Report Date: 07/19/2024
Date Signed: 07/19/2024 04:18:17 PM

Document Has Been Signed on 07/19/2024 04:18 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 SIERRA MADRE RCFEFACILITY NUMBER:
198603560
ADMINISTRATOR/
DIRECTOR:		VARGAS, HECTORFACILITY TYPE:
740
ADDRESS:161 W. SIERRA MADRE BLVD.TELEPHONE:
(626) 355-1447
CITY:SIERRA MADRESTATE: CAZIP CODE:
91024
CAPACITY: 40CENSUS: 34DATE:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Hector Vargas - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Hector Vargas, Administrator and explained the purpose of the visit. Facility is licensed for 40 residents age range 60 and over, of which 30 ambulatory and 10 non-ambulatory; approved hospice waiver for (5) hospice residents.There are currently (34) residents, 60 years and older residing in the facility, (0) bedridden and (0) hospice residents. Residents residing in the facility receive case management services provided by San Gabriel Pomona Regional Center. 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 observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Emergency and disaster plan was completed and up to date.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Facility does not accept nor retain residents with dementia. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expired 07/15/2024. Administrator stated that it has been renewed and will send a copy of the current/valid liability insurance to LPA. Surety bond in the amount of $30,000.00 is in place. Fire drill was last conducted on 06/19/2024.
Physical Plant/Environment Safety: The facility is a single story building located in a commercial area. The facility consists of (2) separate buildings: 1st building (single story) consists of (20) resident rooms and (14) bathrooms, (5) community shower rooms. Outside patio, Medication room, Laundry room, Living room, Dining area, Kitchen and Pantry. 2nd building (2 story) consists of Administrative office, Medical Office, Storage room, Detached garage, Conference room and Accounting Office (upstairs). The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility is equipped with cameras in the common areas. The bathrooms were observed to be clean and operational. Cleaning supplies and toxic substances are inaccessible to residents. At 2:30pm, LPA along with the Administrator toured and tested hot water temperature in five (5) random resident rooms (Rooms #2, #5, #8, #19 and pubic restroom). Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The kitchen was observed to have sufficient amount of perishable and non-perishable food supplies. LPA observed perishable food was stored in covered containers at the appropriate temperatures. There are cameras without audio in the common areas. Fire extinguishers were observed throughout the facility and were last serviced on 04/24/2024. Smoke detectors, fire sprinklers and pull fire alarm system observed and hard wired to the City of Sierra Madre Fire Department.
*****CONTINUED ON LIC809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2024
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 SIERRA MADRE RCFE
FACILITY NUMBER: 198603560
VISIT DATE: 07/19/2024
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Staffing: A total of (41) staff members provide care and supervision to the residents, including the Administrator. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Administrator's certificate expired on 06/03/2024 but provided proof that renewal was submitted to CCL.
Personnel Records-Training: LPA reviewed (4) staff files. Proof of staff training, Health clearance, Fingerprint/Clearance exemptions, Criminal Record statement, Vaccinations and 1st Aid/CPR training are current.
Resident Rights-Information: Resident personal rights, complaint hotline information and visitors policy posters are posted. Per Administrator, facility provides internet services to all residents and have access to the facility phone.
Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly activity calendar is posted. The facility has a Resident Council and council members/residents meet on a monthly basis.
Food Service: Sufficient food supply is stored in the kitchen and pantry area consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Staff wear hairnets and disposable gloves while preparing food.
Incident Medical and Dental: Medications were reviewed for (5) residents to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are centrally stored and in their original containers. Medications are administered as prescribed by the Physician. Medications are bubbled packed. First Aid kit was observed.
Resident Records/Incident Reports: A total of four (4) resident files were reviewed. They contained Admission Agreements, Physician's Reports, Pre Placement Appraisal, IPP, TB clearance, Functional Capability Assessment, Physician's Orders, Medical Consent, Medication Records, and P & I Money Records.
Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place.
Residents with Special Health Needs: Three (3) residents are receiving home health services. There are no residents with prohibited health conditions.

No deficiencies cited. Exit interview conducted and a copy of the report was provided to Hector Vargas, Administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC809 (FAS) - (06/04)
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