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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607079
Report Date: 11/02/2021
Date Signed: 11/02/2021 03:06:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2021 and conducted by Evaluator Noemi Galarza
COMPLAINT CONTROL NUMBER: 28-AS-20211028100111
FACILITY NAME:CLIMB, INC. - RCFE 1FACILITY NUMBER:
197607079
ADMINISTRATOR:JOHN NGUYENFACILITY TYPE:
740
ADDRESS:1319 SOUTH GLADYS AVENUETELEPHONE:
(626) 288-0354
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY:6CENSUS: 4DATE:
11/02/2021
UNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Michael Castillo, DSPTIME COMPLETED:
02:59 PM
ALLEGATION(S):
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Staff are not following COVID 19 screening guidelines.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial complaint visit to investigate the above allegation. The purpose of the visit was discussed with day program staff Michael Castillo. Administrator was explained the purpose of the visit telephonically.

The investigation consisted of the following: A physical plant tour of the facility was conducted to check for COVID-19 visitor screening procedures, infection control practices, and posted signs. Staff (S1- S5) were interviewed. None of the clients were interviewed due to non-verbal ability and cognitive impairments. LPA requested a copy of the COVID-19 Mitigation Plan, staff and resident rosters; but they were not available. Administrator will submit all documents by tomorrow. Per interviews conducted the findings indicate that on 10/13/2021 a visitor conducted an unannounced visit and was not for screened by staff for COVID-19 virus. During today's visit LPA was not screened upon entry. Staff interviews confirmed that staff did not screen the visitor and were subsequently retrained on infection control. Per facility COVID-19 Mitigation Plan staff are to screen all visitors upon entry and shall require all visitors to use a face mask. A deficiency was cited.

Exit interview was conducted with staff Micheal Castillo. A copy of the report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20211028100111
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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, INC. - RCFE 1
FACILITY NUMBER: 197607079
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2021
Section Cited
HSC
1560(c)
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Suspension and Revocation. Conduct which is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home.

This requirement is not met as evidenced by:
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Administrator shall re-train all staff on COVID-19 infection control screening protocols and infection control procedures. Submit proof of staff re-training by tomorrow.
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Based on interviews conducted on 10/13/21 a visitor entered the facility and was not screened by staff on duty. During today's visit, LPA was not screened by staff. This poses an poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC9099 (FAS) - (06/04)
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