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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603560
Report Date: 08/28/2025
Date Signed: 08/28/2025 04:58:44 PM

Document Has Been Signed on 08/28/2025 04:58 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
MONTEREY PARK ASC, 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: 38DATE:
08/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:18 PM
MET WITH:Hector Vargas, Administrator TIME VISIT/
INSPECTION COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA) Daniel Konishi 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 a updated Infection Control Plan in place. 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 or retain residents with dementia. LPA reviewed the Liability Insurance that is in place. LPA reviewed the Surety bond that is in place. Fire and Earthquake drill was last conducted on 07/09/2025.

Physical Plant/Environment Safety: The facility is a single-story building located in a commercial area. The facility consists of (2) separate buildings: the 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.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CLIMB SIERRA MADRE RCFE
FACILITY NUMBER: 198603560
VISIT DATE: 08/28/2025
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Physical Plant/Environment Safety [Cont.]: The 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. LPA inspected five (5) residents' rooms and each resident bedroom has the required furniture such as the bed, bed frames, nightstand, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. The bathrooms were observed to be clean and operational. Each resident rooms had a bathroom that included a water basin and toilet. Cleaning supplies and toxic substances are inaccessible to residents. The LPA along with the Administrator toured and tested hot water temperature in five (5) random resident rooms (Rooms #5, # 9, 11, 12, 19 and shared shower room). Water temperature readings measured between 105.0 degrees F and 111.3 degrees F within the required 105 - 120 degrees Fahrenheit. LPA measured the Shared Shower room hot water temperature at 110.3 degrees F which is within the required 105 – 120 degrees F. Sharps are kept locked and inaccessible from residents. Cleaning supplies are kept locked and inaccessible from residents. There are cameras without audio in the common areas. Carbon Monoxide detectors were tested and working properly. Fire extinguishers were observed throughout the facility and were last serviced on 04/15/2025. Smoke detectors, fire sprinklers and pull fire alarm system observed and hard wired to the City of Sierra Madre Fire Department.

Staffing: There are sufficient staff to 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 are associated to the facility.

Personnel Records-Training: LPA reviewed five (5) staff files includes: Personnel Record, Health clearance, TB Result, Criminal Background Clearance, Employee Rights, 1st Aid/CPR training are current. Administrator's certificate expires on 06/23/2026.

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.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CLIMB SIERRA MADRE RCFE
FACILITY NUMBER: 198603560
VISIT DATE: 08/28/2025
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Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. Outdoor has a shaded area for activity purposes. 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: Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. There are five (5) residents that have a modified diet. 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.



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. The first aid kit was observed and has all required items.

Resident Records/Incident Reports: LPA reviewed five (5) resident files that include: the Face Sheet, Admission Agreements, Physician's Reports, Ambulatory Status, TB Clearance, Individual Program Plan (IPP), and Personal Rights.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place with contact numbers and at least 2 relocation sites.

Residents with Special Health Needs: Three (3) residents are receiving home health services. There are three (2) residents with a Restricted Health Condition and the LPA reviewed the current Restricted Care Plans in file. There are no residents with prohibited health conditions.

Per the California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during today’s visit. Exit interview was held and a copy of the report was provided to Hector Vargas, Administrator.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4