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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601502
Report Date: 07/12/2024
Date Signed: 07/12/2024 02:44:21 PM

Document Has Been Signed on 07/12/2024 02:44 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/
DIRECTOR:		HAMILTON, DAVIDFACILITY TYPE:
735
ADDRESS:872 N RAYMOND AVETELEPHONE:
(626) 792-8813
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 22CENSUS: 9DATE:
07/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Monique Jordan - Interim Administrator
Carmelita Bernardo - DSP I & II
Maria DeCaballero - DSP I & II		TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Carmelita Bernardo, Direct Support Professional I & II (DSP I & II), Maria DeCaballero, Direct Support Professional I & II (DSP I & II) and explained the purpose of the visit. At 10:30am, Monique Jordan, Administrator arrived and assisted LPA with the inspection. The facility is licensed to care for twenty two (22) Developmentally Disabled Adults ages 18 through 59, ambulatory only. All clients residing at this facility receive case management services provided by Frank D. Lanterman Regional Center. 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. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 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 2 story home located in a residential neighborhood, contains a total of (11) client bedrooms, of which (4) are located downstairs, and (7) are located upstairs, (5) bathrooms, of which (3) are upstairs and (2) are downstairs, office/storage supplies room, a living room, dining area, kitchen, backyard, front porch with shaded sitting area and detached garage next to a laundry area. Currently, there are (9) clients living in the facility. 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. Carbon monoxide operable, smoke detectors/ fire alarms are hard wired to the Fire Department of Pasadena. LPA observed that there is no window covering in bedroom #3. The floor tiles in bathroom #1 are chipped and broken. Bathroom #3 upstairs has mold/mildew in the shower area. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and the area provides outdoor furniture and shade. LPA observed that one of the garage doors was broken, and ceilings are damaged with severe cracks. Cleaning supplies, and toxic substances are locked in the storage cabinet along with medication. There are (4) fire extinguishers observed which were last serviced on 08/30/2023. There are no firearms or weapons stored at the facility. Facility does not have a video camera monitor system. Water temperature readings measured were not within the required 105 - 120 degrees Fahrenheit. At 9:45am, hot water supply measured at 123.4 deg F in bathroom #1, 123.9 deg F in bathroom #2 and 126.6 deg F in bathroom #4 upstairs. At 12:45pm, LPA re-measured the hot water temperature and are now within the required 105-120 deg F.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is in place. Surety Bond Insurance with bond amount of $18000 is valid and will expire on 01/13/2025. Last Fire Drill was conducted on 06/24/2024 and according to the Interim Administrator, emergency drills are conducted on a monthly basis. *****REPORT CONTINUED ON LIC809-C****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOUSE
FACILITY NUMBER: 198601502
VISIT DATE: 07/12/2024
NARRATIVE
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Staffing: A total of eleven (11) staff members including the Interim Administrator 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 associated to the facility.
Personnel Records/Staff Training: Reviewed files for six (6) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and will expire on 04/06/2025. Administrator has HIV/AIDS training.
Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. Administrator also stated that only one (1) client has a cell phone and three (3) have their own tablet/IPad. LPA did not conduct client interviews as all (9) clients were in the Day Program at the time of the visit.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C5. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. Plates, cups and utensils are kept cleaned and stored properly. LPA observed a gallon of cleaning solution stored next to the food supplies and staff immediately removed it. Staff stated that they only prepare breakfast for the clients, lunch and dinner are prepared outside the facility.
Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for C1-C4 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. First aid supplies are maintained and readily available in the facility.
Incidental Medical Services: Per the Interim Administrator, no client at this home with a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency Intervention: Not-Applicable.

Deficiencies cited and Technical Violation issued. Exit interview, appeals rights and a copy of this report was provided to the Interim Administrator, Monique Jordan.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 07/12/2024 02:44 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/12/2024 at 01:11 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: 07/12/2024

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 on observation, the licensee did not comply with the section cited above in which water temperature readings measured were not within the required 105 - 120 degrees Fahrenheit. At 9:45am, hot water supply measured at 123.4 deg F in bathroom #1, 123.9 deg F in bathroom #2 and 126.6 deg F in bathroom #4 upstairs which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 07/12/2024
Plan of Correction
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 At 12:45pm, staff re-adjusted the hot water temperature and LPA’s 2nd readings measured within the required 105-120 degrees Fahrenheit, 116.6 deg F in bathroom #1, 116.9 deg F in bathroom #2 and 112.4 deg F in bathroom #4 upstairs. ***DEFICIENCY CLEARED DURING THE VISIT.***
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 07/12/2024 02:44 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/12/2024 at 01:11 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: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that LPA observed the floor tiles are broken in bathroom #1, mold/mildew in the shower area in bathroom #3, one of the garage doors was broken, garage ceilings are damaged with severe cracks and debris, big hole on the wall next to the laundry machine and tree branches on the ground in the backyard which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/02/2024
Plan of Correction
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Interim Administrator will submit proof of corrections for the items mentioned and send LPA/CCL photos, maintenance service reports/invoices on or before the POC due date.
Type B
Section Cited
CCR
80087(i)
Building and Grounds
(i) The items specified in Section 80087(g) above shall not be stored in food storage areas or in storage areas used by or for clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that LPA observed cleaning supplies were stored in a locked cabinet along with food supplies and medication which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 07/12/2024
Plan of Correction
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Staff removed the cleaning supplies and stored it in a different area during the visit. ***DEFICIENCY CLEARED DURING THE VISIT.***
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 07/12/2024 02:44 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/12/2024 at 01:11 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: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(15)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (15) Pesticides and other similar toxic substances shall not be stored in food storerooms, kitchen areas, food preparation areas, or areas where kitchen equipment or utensils are stored.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that LPA observed a gallon of cleaning solution stored next to the food supplies in the kitchen which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 07/12/2024
Plan of Correction
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Staff immediately removed the cleaning solution and stored it in a locked cabinet away from the food supplies. ***DEFICIENCY CLEARED DURING THE VISIT. ***
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024


LIC809 (FAS) - (06/04)
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