Climb, Inc. - RCFE 1

Type of visit: Required - 1 Year

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 as a Residential Care for the Elderly (RCFE) that serves developmentally disabled residents ages 59 and over vendored by Eastern Los Angeles Regional Center. Administrator certificate expires 10/1/2026.. Infection Control: The facility has an Infection Control Plan that is reviewed annually. Operational Requirements: A hospice waiver for 2 residents is in place. Fire clearance is approved for 6 non-ambulatory residents who are legally blind. Facility handles resident P & I monies. The Surety Bond is current. 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 7/15/2027. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood. There are 4 resident bedrooms, living room, dining room, family room, kitchen, laundry area, 3 bathrooms, backyard patio area, and detached garage/storage. All bedrooms are equipped with required furniture, bedding, mattress pad, and lighting. Cleaning supplies, knives, and toxic substances are inaccessible to residents. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The facility has a 1st Aid Kit and manual. The facility has two (2) fire extinguishers. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility is equipped with a sprinkler system, smoke/carbon monoxide detectors. The last fire inspection was conducted on 9/22/2025 by San Marino Security Systems, Inc. Staffing: A total of 15 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Four (4) staff files were reviewed. Criminal background clearance, staff training, health screening & TB clearance, DSP, 1st Aid/CPR, and, CEU's are on file. Resident Records/Incident Reports: Four (4) resident files were reviewed. Admission agreements, Physician's Report, HCBS Tenant/Landlord Agreements, medical/functional assessments, ISP's & Functional Behavior Assessment, TB clearance, IPP reports, personal rights, medical consent, dietician report, consultant logs, P & I records, and Medication Administration Records were reviewed. Personal & Incidental (P & I) monies/records are maintained at the corporate office. Ledgers were emailed and reviewed by LPA. RCFE and Ombudsman complaint posters are posted. A technical advisory was issued because the RCFE poster is not the correct size. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility does not have a Resident Council. Food Service: Food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. All residents require modified diets. Incident Medical and Dental: Residents are assisted with self administration of prescription and non-prescription medications. The medications are centrally stored and in their original containers. The facility uses a Medication Administration Record (MAR) log. Centrally stored resident medication records were reviewed and are given according to Physician directions. 30-Day supply of medications were reviewed. The facility is equipped with one van. Medical and dental transportation is provided by the facility. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. Residents with Special Health Needs: One (1) resident receives home health services. No residents have prohibited health conditions. All residents require adaptive equipment. Disaster Preparedness, and Emergency Intervention: Emergency Disaster Plan was reviewed. The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility. First Aid Kit and Manual were observed. The last Emergency Disaster drill was conducted on 5/9/2026. Emergency Intervention: Staff are trained CPI de-escalation techniques. No deficiencies were cited. Exit interview was conducted with Administrator John Nguyen. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 17, 2026

Allegation investigated: Facility is operating out of ratio. Staff did not adhere to resident's care plan.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the above allegations. The purpose of the visit was explained to day program staff Eric Hanson. Administrator John Nguyen arrived shortly after. The investigation consisted of: A physical plant tour of the facility common areas and resident rooms was completed. Staff (S1- S2) and resident (R1 & R2) were interviewed. Residents (R3 & R4) are non-speaking. File review was conducted. Copies of resident (R1's) Face Sheet, ISP, IPP, Medical Assessment, staff schedule (4/13/26), program design staffing information, LIC 500 Personnel Report, and resident roster were obtained. A copy of the Regional Center Corrective Action Plan (CAP) was obtained. *Report continuation on 9099C. Substantiated Allegation: Facility is operating out of ratio. It is alleged that on April 13, 2026, a Regional Center representative observed a 1:3 staff-to-client ratio, instead of a 1:2 staff-to-client ratio. At the time of the visit, only one day program staff member was present. At approximately 2:00 PM, another resident returned, increasing the ratio to 1:4 staff-to-client ratio. According to information obtained, there was no direct care staff on site, and none were scheduled until 2:30 PM – 3:00 PM, resulting in a staffing gap. As a result, the day program staff remained on duty until one direct care staff arrived at 2:30 PM. At 2:50 PM, a 2nd DSP staff arrived. Residents stated there are two staff present during shifts. A total of two (2) staff were interviewed. The facility is a level 6 facility with a staffing ratio of 1:2 staff-to-client ratio, and the Climb Day Program operates with a 1:3 staff-to-client ratio. Staff interviewed stated that during the pandemic day program staff began providing remote services at the facility, and have continued the practice since then. Administrator stated that on 4/13/2026, there were 3 residents in the home and one staff meeting day programming staff ratios. However, based on facility and day program plan of operation review, the findings reveal that the facility and day program plan of operation do not state day program staff are authorized to provide in-home services. The findings indicate that if a day program staff member is assigned to work at the home and meets all DSP requirements, they may fill in as DSP staff only. However, they cannot function as both DSP and day program staff at the same time, as those are two separate authorizations. On May 5, 2026, the Regional Center issued a Corrective Action Plan (CAP). Therefore, There is sufficient information to corroborate the allegation. Allegation: Staff did not adhere to resident's care plan. The complaint alleges resident (R1) did not want to attend scheduled day program, but despite the resident’s preference staff directed the resident to participate in the In-Home Day program rather than honoring the individual’s choice to decline services for the day. Staff interviewed stated that resident (R1) is allowed to stay home if they do not want to attend the day program, and the resident chooses his activities i.e., watching Youtube, texting, and playing on their computer. Resident (R1) communicated they are allowed to stay home whenever they want. Per record review, the findings indicate the facility did not follow resident (R1’s) person-centered service plan requirement of providing DSP staffing coverage, which resulted in inadequate supervision and limiting R1 the right to make choices regarding day program participation. Based on file review, the home shall provide enhanced staffing and support through DSP services, and not through in-home day programming services. Therefore, the allegation is supported. Based on record review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Pursuant to Title 22, California Code of Regulations, deficiencies are cited. An exit interview was conducted, copy of the report and appeal rights was provided to Administrator John Nguyen.the state’s words, verbatim · CDSS document, May 26, 2026 · control 28-AS-20260519084731

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jun 23, 2026

Personnel Requirements. Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.... This requirement was not met evidenced by: Based on interviews and record review, on 4/13/2026 the facility failed to meet required Regional Center staff-to-client ratio of 1:2. A 1:3 staff-to-client ratio was observed, and the only staff present was a day program staff and not a DSP staff, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Administrator agreed to submit a written plan of correction that includes a revised staffing schedule and back-up staffing plan to address staffing gaps and call offs. The plan shall include information about day program staff use in the home. *NOTE: per plan of operation, day program staff are not authorized to work in the home.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jun 23, 2026

Additional Personal Rights of Residents in Privately Operated Facilities.... residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on interviews and record review, the findings indicate the facility did not provide required DSP staffing coverage, resulting in inadequate supervision; therefore, limiting R1's right to make choices regarding participation in day program services, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Administrator agreed to submit a written plan that includes R1's needs and services plan and individual needs. In addition, Administrator agreed to conduct HCBS final rule training to all staff regarding individual choices.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced annual inspection visit. The purpose of the visit was explained to DSP Eric Hanson. The facility is vendored by Eastern Los Angeles Regional Center as a level 4B Specialized. The facility serves elderly developmentally disabled residents 60 years and older. Currently there is one (1) resident under the age of 59. The following were observed/inspected: Infection Control: The Infection Control Plan was reviewed and includes environmental cleaning and disinfection activities. The facility has cleaning supplies. Operational Requirements: A hospice waiver for 2 residents is in place. A fire clearance for 6 non-ambulatory residents who are legally blind is in place. Facility handles resident P & I monies. The Surety Bond is current. 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 7/15/2026. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood. It consists of 4 client bedrooms, living room, dining room, family room, kitchen, laundry area, 3 bathrooms, backyard patio area, and detached garage. The facility is equipped with a sprinkler system. Smoke and carbon monoxide detectors were tested and are operational. The facility has one (1) fire extinguisher. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The facility has a 1st Aid Kit and Manual. Cleaning supplies, knives, and toxic substances are inaccessible to residents. Exit doors are free of any obstruction and there are no pools or large bodies of water. Staffing: A total 10 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 10/1/2026. Staff have criminal background clearance and training. Six (6) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training is current. Resident Records/Incident Reports: A total of four (4) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, ISP's, quarterly reports, TB clearance, Physician's Orders, medical consent, personal rights, medication administration records, and consultant logs. Personal & Incidental (P & I) monies/records are at corporate office. P & I money records were reviewed. RCFE and Ombudsman complaint posters are posted in the main entryway of the facility. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility does not have a Resident Council. Food Service: Food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Residents have modified diets. Incident Medical and Dental: Centrally stored resident medications were reviewed. 30-day supply of client medications were observed locked and given as prescribed. Medical and dental transportation is provided by the facility. The facility is equipped with one van. Residents have updated consultant assessments, Physician Reports, physician orders, and COVID-19 vaccination cards on file. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. Residents with Special Health Needs: One (1) resident receives home health services. No residents have prohibited health conditions. All residents require adaptive equipment. Disaster Preparedness, and Emergency Intervention: Emergency Disaster Plan was reviewed. The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility. First Aid Kit and Manual were observed. The last Emergency Disaster drill was conducted on 8/6/2025. Emergency Intervention: No manual restraints or seclusion is used in the facility. No deficiencies were cited. Exit interview was conducted with Administrator John Nguyen. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 22, 2025

Type of visit: Required - 1 Year

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.***** 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.the state’s words, verbatim · CDSS document, Aug 29, 2024