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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601502
Report Date: 09/15/2023
Date Signed: 09/15/2023 02:57:08 PM

Document Has Been Signed on 09/15/2023 02:57 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:
09/15/2023
TYPE OF VISIT:Case Management - Annual ContinuationANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Administrator Cheryl Jackson TIME COMPLETED:
02:55 PM
NARRATIVE
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LIcensing Program Analyst(s) (LPA) Ashley Calderon conducted a case management annual continuation visit at the above facility with focus on using the CARE Inspection Tool. LPA Calderon met with DSP staff #2 (S2) and explained the reason for the visit. Administrator Cheryl Jackson arrived at 10:15AM.

On today's visit, LPA interviewed a total of (3) staff , (2) clients and attempted (2) client interviews.

LPA observed alongside with Cheryl Jackson/ Administrator, facility refrigerator and freezer, having no thermometer in place. LPA interviewed Administrator and Staff #2 who confirmed no thermometers in place in the freezer and refrigerator, deficiency cited.

LPA continued questions on CARE tools to complete annual inspection. LPA reviewed training's, (5) client files and (4) staff files. During LPA record review for clients file review, Client #8 (C8) did not have admission agreement in place, LPA observed record of client#8 (C8) and had Administrator assist to locate admission agreement, admission agreement was not placed in file, deficiencies cited.

LPA reviewed medication and medication records for (3) clients in care, no deficiencies noted.

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: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023
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 09/15/2023 02:57 PM - It Cannot Be Edited


Created By: Ashley Calderon On 09/15/2023 at 02:12 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: 09/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(2)
Food Service 85076(d)(2) Freezers shall be large enough to accommodate required perishables and shall be maintained at a temperature of zero degrees F (17.7 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Calderon and Admin. Cheryl Jackson's observations and interviews with Administrator and Staff #2, no themometer in place in freezer, the licensee did not comply with the section cited above in 9 out of 9 persons/clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Administrator will submit photos to LPA Calderon of (2) thermometers placed in the freezer.
Type B
Section Cited
CCR
85076(d)(3)
Food Service (d)(3) Refrigerators shall be large enough to accommodate required perishables and shall maintain a maximum temperature of 45 degrees F (7.2 degrees C).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Calderon and Admin. Cheryl Jackson observations and interview with Admin. and Staff #2, no thermometer in place in the refrigerator, 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
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Administrator will provide picture of refrigerator thermometer placed in refrigerator.
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: 09/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/15/2023 02:57 PM - It Cannot Be Edited


Created By: Ashley Calderon On 09/15/2023 at 02:27 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: 09/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)
(a)The licensee shall complete an individual written admission agreement with each client and the client's authorized representative.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Calderon and Administrator observations, and Admin. interview and record review for client #8 (C8), C8 had missing admission agreement in client's file. The licensee did not comply with the section cited above in 1 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
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Administrator will provide a copy of client #8 admission agreement to LPA via email.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2023


LIC809 (FAS) - (06/04)
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