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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601502
Report Date: 02/14/2023
Date Signed: 02/14/2023 02:31:18 PM

Document Has Been Signed on 02/14/2023 02:31 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
GREATER LA AC/SC, 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: 10DATE:
02/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Vernon Langston - Staff TIME COMPLETED:
02:45 PM
NARRATIVE
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LIcensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control domain, medication and food review. LPA Flores met with Stefon Jordan staff and explained the reason for the visit. Vernon Langston pending administrator arrived 10 minutes later.

Facility is licensed to served (22) twenty two ambulatory only developmentally disabled adults 18 - 59 years old. The facility is a two story home located in a residential neighborhood and consist of a kitchen, a total of (11) client bedrooms of which (4) are located downstairs, and (7) are located upstairs, (5) client bathrooms of which (3) are upstairs and (2) are downstairs, a detached garage with a laundry, backyard and front porch with shaded sitting area.

LPA Flores conducted a tour of the facility with Vernon Langston staff and observed the following:
One central point of entry to the facility with a screening station and proper signage. Sitting area in the entrance is provided for visitors. Living room and dining room were observed clean and in good condition. Kitchen was observed clean and sufficient food was observed per staff dinner gets prepare at the sister home and brought to the home. LPA advice a food preparation waiver for meals to be prepared outside the facility is to be submitted to the department by 2/24/23. LPA observed 10 client rooms rooms have sufficient lighting, furniture, and bedding supplies. Room #10 has water damage and mold due to the rain in the ceiling of approximately 3ft by 4ft long. Room is currently vacant and a work order was placed on 2/12/23. LPA did not observed room #11 as client keeps it lock and was out for the day. 5 bathrooms were observed to be in working condition, hand washing signs were not observed, water temperature was tested between 59.1 - 122 degrees F which is not within the required 105-120 degrees F. Fire sprinkle system was observed and fire extinguishers were last reviewed on 8/15/22. Administrator certificate for Vernon Langston is pending #6065879735 documents were received by the administrator certificiation division on 1/17/23. LPA reviewed medication for 3 clients.
Deficiencies were noted per Title 22 Regulations. Exit interview was conducted with Vernon Langston - Staff and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2023
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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Document Has Been Signed on 02/14/2023 02:31 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/14/2023 at 02:10 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: 02/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) 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:
Deficient Practice Statement
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Based onobservation the licensee did not comply with the section cited above in bathroom #2 water tested at 122 degrees F., bathroom #3 water tested at 121.1 degrees F., bathroom #4 water tested at 59.1 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2023
Plan of Correction
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Licensee will ensure water temperature is maintain within the required 105-120 degrees F. at all times, will adjust water heater, and will submit LIC 9098 to certify by 2/15/23 and maintain a water temperature log for the next 7 days for each bathroom and submit to the department by 2/21/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023


LIC809 (FAS) - (06/04)
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