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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607079
Report Date: 08/29/2024
Date Signed: 08/29/2024 12:58:16 PM

Document Has Been Signed on 08/29/2024 12:58 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CLIMB, INC. - RCFE 1FACILITY NUMBER:
197607079
ADMINISTRATOR/
DIRECTOR:		JOHN NGUYENFACILITY TYPE:
740
ADDRESS:1319 SOUTH GLADYS AVENUETELEPHONE:
(626) 288-0354
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY: 6CENSUS: 4DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:John Nguyen, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to Administrator John Nguyen. The facility is licensed for 6 elderly developmentally disabled residents 60 years and older. One (1) current resident is under the age of 59. The facility is licensed as a level 4B Specialized vendored by Eastern Los Angeles Regional Center. The following 12 Care Compliance and Regulatory Enforcement (CARE) tool domains were utilized during the inspection.

The following were observed/inspected:



Infection Control: The Infection Control Plan was reviewed. The facility has a supply of Personal Protective Equipment (PPEs).

Operational Requirements: No hospice or Dementia waiver is in place. A fire clearance for 6 non-ambulatory residents age 60 and above, who are legally blind is in place. Facility handles resident P & I monies and has a current Surety Bond. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 7/15/2025.

Physical Plant/Environment Safety: 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. Cleaning supplies and toxic substances are inaccessible to residents. The facility has one (1) fully charged fire extinguisher. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Facility has a fire pull-alarm in the dining area and heat detectors.

Staffing: A total of 12 staff members provide care and supervision to the clients.

Personnel Records/Staff Training: Administrator certificate expires 10/1/2024. Staff have criminal background clearance and training. Four (4) staff files were reviewed. Proof of staff training, health and TB clearance, and 1st Aid/CPR training are on file. Two (2) staff (S5 & S6) are day program staff that assist in the mornings at the facility, neither staff have files on-site. Deficiency was cited.


****Report narrative continues next page.*****

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CLIMB, INC. - RCFE 1
FACILITY NUMBER: 197607079
VISIT DATE: 08/29/2024
NARRATIVE
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Resident Records/Incident Reports: Four (4) resident files were reviewed. They contained admission agreements, IPPs, Behavior Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. Centrally stored medication records are in place.

RCFE complaint poster and Personal rights were observed posted. However, the RCFE Poster is 8 x 10, instead of 20 x 26 inches. A technical advisory was issued.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility does not have a Resident Council.

Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. One resident has a modified diet plan.

Incident Medical and Dental: Four (4) centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by facility staff.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 5/1/2024.

Residents with Special Health Needs: No residents are receiving hospice services or home health services. No residents have prohibited health conditions. Full bed rails for mobility assistance were observed in resident (R1's) room. However, R1 is not enrolled in hospice. Therefore, a deficiency was cited.

Per California Code of Regulations, Title 22, deficiencies were cited.



Exit interview was conducted with Administrator John Nguyen.A copy of the report and appeal rights was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
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Document Has Been Signed on 08/29/2024 12:58 PM - It Cannot Be Edited


Created By: Noemi Galarza On 08/29/2024 at 12:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that (R1) is not enrolled in hospice and their bed had full bed rails; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Staff removed the rails during the visit. Submit a copy of the half-rail physician order and picture evidence.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/29/2024 12:58 PM - It Cannot Be Edited


Created By: Noemi Galarza On 08/29/2024 at 12:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that personnel files/records were not on site/available for review for staff (S5 & S6; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2024
Plan of Correction
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Administrator agreed to submit a written statement of how the deficiency was corrected and will ensure all staff that work at the facility have required forms on file.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


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