<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601502
Report Date: 09/14/2023
Date Signed: 09/14/2023 05:26:46 PM

Document Has Been Signed on 09/14/2023 05:26 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: 9DATE:
09/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Administrator Cheryl Jackson TIME COMPLETED:
05:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LIcensing Program Analyst(s) (LPA) Ashley Calderon conducted an unannounced annual visit at the facility with focus on using the CARE Inspection Tool. LPA Calderon met with DSP staff Quincy Tripp and explained the reason for the visit. Administrator Cheryl Jackson arrived at 2pm, LPA explained reason for the visit.

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 (3) are upstairs and (2) are downstairs, a detached garage with a laundry, backyard and front porch with shaded sitting area. Attic is empty and inaccessible to clients in care. Facility phone number: 626-792-8814 .
LPA Calderon conducted a tour of the facility with Cheryl Jackson and observed the following:

Living room and dining room were observed clean and in good condition. Kitchen was observed and had working appliances and facility meals are prepared outside the facility, at the sister facility, Bella Vista. Facility has extra food for clients in care and can goods/ dry foods. LPA observed random client rooms.
Client #1, Client #2, Client #3, Client #4 (C1-C4), all bedrooms had sufficient lighting and bedding supplies. LPA observed C1-C4 not having adequate furniture: missing chairs and night stands, deficiencies were cited.

Downstairs bathrooms were observed to be in working condition, water temperature was tested within the required 105-120 degrees F. Bathroom upstairs near C3 bedroom did not deliver hot water in sink deficiencies were cite, far end bathroom was clean, operable and hot water was tested and measured within Title 22 regulation. Upstairs also had a staff only bathroom that is kept locked and inaccessible to clients in care. LPA during visit observed maintenance being done on floors upstairs, LPA interviewed handy man from Lozano Iron Works and confirmed repairs on downstairs flooring and walls is scheduled. LPA asked for pictures once completed. LPA did not observe evacuation chair in stairways, deficiencies were cited.

Carbon monoxide operable, smoke detectors/ fire alarms are hard wired to the Fire Department of Pasadena. Fire Drill conducted: 9/5/23.

Continuation 809-C...


SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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
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: 09/14/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
  • No fireplace observed.
  • Administrator Certification expires on: 11/6/23.
  • Facility is responsibility for clients P & I's.
  • LPA observed sufficient linen and towels in upstairs closet.
  • Sharps located in Office room inaccessible to clients.
  • Medications were kept locked in storage room near facility entrance which also contains hygiene supplies, paper goods, first aid kit and cleaning supplies.


LPA will continue annual inspection at another time, due to insufficient time.

Deficiencies were noted per Title 22 Regulations. Exit interview was conducted with Administrator Cheryl Jackson and a copy of this report, LIC 809D, and appeal rights were provided via email to Administrator due to LPA's printer issues.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 09/14/2023 05:26 PM - It Cannot Be Edited


Created By: Ashley Calderon On 09/14/2023 at 04:20 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: 09/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview with Administrator no nightlights in place in passways/ hallways, the licensee did not comply with the section cited above in 9 out of 9 clients/ persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
1
2
3
4
Administrator will notify Licensee and facility will purchase nightlights. Administrator will provide LPA with pictures and reciepts of purchased items.
Type B
Section Cited
HSC
1565(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell in a residential facility serving adults, on or before July 1, 2021.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation no evacuation chairs in place and interview with Administrator stated facility not containing evacuation chairs, the licensee did not comply with the section cited above in 9 out of 9 persons/cleintswhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
1
2
3
4
Facility will provide LPA Calderon with pictures of purchased evacuation chairs for (2) stairways.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4