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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607079
Report Date: 11/02/2021
Date Signed: 11/02/2021 03:57:07 PM

Document Has Been Signed on 11/02/2021 03:57 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, 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
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Anthony Dulay, DSPTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with DSP staff Anthony Dulay and explained the purpose of the visit. Administrator John Nguyen was explained the purpose of the visit telephonically. There are four (4) developmentally disabled clients ages 18-59 in the specialized home serviced by Eastern Los Angeles Regional Center. The facility is a single story home located in a residential neighborhood that is licensed for 6 non-ambulatory clients. The facility serves legally blind clients. It consists of 4 client bedrooms, living room, dining room, family room, kitchen, laundry area, 3 bathrooms, backyard patio area, and detached garage. The last fire drill was conducted on 8/5/2021. Administrator certificate expires 10/1/2022.

The following were observed/inspected:
  • The interior and exterior physical plant was inspected.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • COVID-19 Infection Control signs were observed in the entrance, common areas, hallways, and bathrooms. However, LPA was not screened upon entry by day program staff. A citation was issued under complaint control # 28-AS-20211028100111.
  • Each client's room is designated as a COVID-19 isolation room if needed.
  • Four (4) centrally stored resident medication records were reviewed.
  • Staff were observed wearing surgical masks.
  • Clients in care do not wear masks because it is not tolerated due to cognitive impairment.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A posted Emergency Disaster Plan was observed.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Staff and resident files were not reviewed during today's visit.
No deficiencies were cited.
Exit interview was conducted with staff Anthony Dulay. A copy of the report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR 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.

LIC809 (FAS) - (06/04)
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