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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601502
Report Date: 05/14/2026
Date Signed: 05/14/2026 04:52:48 PM

Document Has Been Signed on 05/14/2026 04:52 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:RAYMOND HOUSEFACILITY NUMBER:
198601502
ADMINISTRATOR/
DIRECTOR:		HAMILTON, DAVIDFACILITY TYPE:
735
ADDRESS:872 N RAYMOND AVETELEPHONE:
(626) 792-8813
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 22CENSUS: 0DATE:
05/14/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:36 PM
MET WITH:Greg Tillman, StaffTIME VISIT/
INSPECTION COMPLETED:
05:01 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required-1 year visit. Upon arrival, no one answered the door and LPA called the facility number. At 2:57pm, Staff, Greg Tillman arrived and LPA explained the purpose of the visit. Staff #3 (S3) helped assist with the visit. Shortly after, Ann Hamilton, Acting Administrator arrived and LPA explained the purpose of the visit. The facility is licensed to care for twenty-two (22) Developmentally Disabled Adults ages 18 through 59, ambulatory only.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Staff clean and disinfect surfaces in the common areas on a regular basis. Staff are trained in the proper use of all required PPEs. Staff are adhering to infection control requirements.

Physical Plant/Environment Safety: The facility is a two-story home located in a residential neighborhood, has a total of eleven (11) client bedrooms, with four (4) on the ground floor and seven (7) on the upper floor. There are five (5) bathrooms, with three (3) on the upper floor and two (2) on the lower floor. The facility also has a front porch with a shaded sitting area, office/storage supplies room, living room, dining area, kitchen, detached garage close to a laundry room, and backyard. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Extra Linens and Towels are in the 2nd floor closet. The facility has two (2) evacuation chairs mounted on the wall nearby the stairway and 2nd floor exit door. Carbon monoxide operable, smoke detectors/fire alarms are hard wired to the Fire Department of Pasadena. There are no pools or large bodies of water. [Continue to LIC809-C]

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: RAYMOND HOUSE
FACILITY NUMBER: 198601502
VISIT DATE: 05/14/2026
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Backyard was inspected and the area provides outdoor furniture and shade. Cleaning supplies and toxic substances are locked in the storage cabinet. There are (4) fire extinguishers observed which are fully charged. Facility does not have a video camera monitor system. Hot water temperature readings measured between 105.0 degrees to 111.9 degrees F which are required 105 - 120 degrees Fahrenheit.

Operational Requirements: The Infection Control Plan has been added to the Plan of Operation. A fire clearance is in place. Surety Bond Insurance is in place. Emergency drills are conducted on a monthly basis and the last fire drill was last conducted on 06/19/2025

Staffing: A total of (15) staff members including the Acting Administrator and (1) on-call staffing provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility.

Personnel Records/Staff Training: LPA reviewed three (3) staff files: Personnel Record, Staff training, health clearance, TB clearance, and First Aid/CPR/AED training in file. Acting Administrator certificate is valid and will expire on 11/01/2026. Acting Administrator has an updated HIV/AIDs training in file.

Client Rights-Information: Client personal rights are posted. Facility provides internet services to all clients and have access to the facility phone.

Client Records-Incident Reports: LPA did not review clients files since there are currently no clients living at the facility.

Food Service: LPA toured the kitchen which appeared clean and the appliances and fixtures functional. The facility kitchen was observed to be clean at the time of inspection. The facility has no clients living at the facility so there are currently no 2-day perishable and 7-day non-perishable food supply.

Health Related Services: The facility has a medical cart to store medications. LPA did not review medications since there are no clients at the facility.

Incidental Medical Services: Currently there are no clients in the facility. Therefore, there are no clients with restricted health conditions.

Disaster Preparedness: The facility has an updated Emergency Disaster Plan and at least two (2) relocation sites. Facility maintains documentation of the required emergency drills.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: RAYMOND HOUSE
FACILITY NUMBER: 198601502
VISIT DATE: 05/14/2026
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Emergency Intervention: Not applicable. Facility does not use restraints or seclusion.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. Exit interview was held and a copy of this report were provided to the Staff, Greg Tillman.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
LIC809 (FAS) - (06/04)
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