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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607079
Report Date: 08/03/2022
Date Signed: 08/03/2022 11:29:56 AM

Document Has Been Signed on 08/03/2022 11:29 AM - 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:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Administrator, John NguyenTIME COMPLETED:
11:45 AM
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Licensing Program Analyst's (LPA) Vasallo and Yang conducted an annual required visit. LPA's met with Administrator, John Nguyen and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, residents' medications and records, food supply, and staff records. The facility cares for elderly residents with intellectual disabilities and is vendorized by East Los Angeles Regional Center.

All resident bedrooms were inspected. All bedrooms are private rooms. Each room has a bed, linen, dresser, light, and closet space. The resident bathrooms have the required grabs bars for non-ambulatory residents and have non-skid mats/shower chairs in the shower. The hot water was 105.5 degrees which is within the required 105 - 120 degrees. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances were clean and operating properly. The common areas include the living room and dining room. These areas are clean and have the required furniture. Exit doors are free of any obstruction. There is a screening station at the entrance of the facility to screen visitors. Staff document residents' temperatures and any symptoms daily. Facility currently has at least a 30-day supply of PPEs.

LPA's reviewed all resident records to confirm emergency contacts are updated and health screenings are complete. 4 staff records were reviewed to confirm health screenings, training and fingerprint clearances. All files were complete. LPA reviewed all residents' medications. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held. A copy of the report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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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