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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607079
Report Date: 05/26/2026
Date Signed: 05/26/2026 03:04:32 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
05/19/2026 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260519084731
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:
05/26/2026
UNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:John NguyenTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Facility is operating out of ratio.
Staff did not adhere to resident's care plan.
INVESTIGATION FINDINGS:
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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
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
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 3
Control Number 28-AS-20260519084731
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
VISIT DATE: 05/26/2026
NARRATIVE
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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.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20260519084731
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: 05/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2026
Section Cited
CCR
87411(a)
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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:
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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.

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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.
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Type B
06/23/2026
Section Cited
CCR
87468.2(a)(4)
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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.
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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.

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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.
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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.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3