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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601502
Report Date: 11/16/2021
Date Signed: 11/16/2021 03:23:21 PM

Document Has Been Signed on 11/16/2021 03:23 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:RAYMOND HOUSEFACILITY NUMBER:
198601502
ADMINISTRATOR:HAMILTON, DAVIDFACILITY TYPE:
735
ADDRESS:872 N RAYMOND AVETELEPHONE:
(626) 794-4103
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 22CENSUS: 12DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH: Cheryl Jackson / Administrator
and Bullock Rosline / Staff		TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced visit for the Annual/Required inspection. Upon arrival at the facility, LPA met with Administrator Cheryl Jackson and
Rosline Bullock who assisted with the visit. During today's visit, LPA used the infection control domain.
The facility is licensed to serve twenty-two (22) Developmentally Disabled Clients ages 18 - 59 years of age. Currently there are 12 regional center clients in care. This is a two story home, consisting of: kitchen, four client bedrooms are located downstairs, seven client bedrooms are located upstairs, three client bathrooms upstairs and two bathrooms located downstairs, garage area, laundry area, medication area, backyard and outside covered area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present in the facility.
All the required documents are posted in a clearly visible area, fully charged fire extinguishers, fully stocked first aid kit with current manual and tweezers. During the course of this visit the LPA observed a sufficient number of staff working to meet the needs and provide care & supervision.

All medications are kept locked and inaccessible to the clients. The bathrooms are clean and operational. Client bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The hot water temperature was tested throughout the facility. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.

Front and backyards were well maintained and free of debris, all trash bins with lids, laundry room is located in the backyard storage area, all outside covered areas with chair.

Continued 899C




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SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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: RAYMOND HOUSE
FACILITY NUMBER: 198601502
VISIT DATE: 11/16/2021
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The following concerns were observed during today's visit:
  • At 1:00pm LPA toured the garage and observed laundry detergent in the garage which was kept unlocked and accessible to the clients.
  • At 1: 30pm hot water temperature tested at the downstairs bathrooms and measured at 101.1 degrees F
This poses an immediate health, safety risk to persons in care


The following deficiency was observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted and a copy of this report was provided to the Administrator along with the Appeals Rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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Document Has Been Signed on 11/16/2021 03:23 PM - It Cannot Be Edited


Created By: Nune Margaryan On 11/16/2021 at 02:44 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: RAYMOND HOUSE
FACILITY NUMBER: 198601502

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Buildings and Grounds. Desinfectants, cleaning solutions, poisons, and other items that could pose a danger to clients shall be inaccesable.

This requirement is not met as evidenced by:
At 1:00 pm LPA toured the garage and observed laundry detergant in the garage wich was kept unlocked and was accesable to the clients.

Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2021
Plan of Correction
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Staff confiscated the detergant and make it inaccesable to the clients.
Type A
Section Cited
CCR
80088(e)(1)
Buldings and ground. Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
At 1: 30pm hot water temperature tested at the downstairs bathrooms and measured at 101.1 degrees F
This poses an immediate health, safety risk to persons in care.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2021
Plan of Correction
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Facility staff adjusted the hot water temperature and LPA re-tested the hot water temperature throughout the facility and it was measured within Title 22 Regulation guidelines.

***Citation was cleared at the time of visit and no further action is needed***
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021


LIC809 (FAS) - (06/04)
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