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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601502
Report Date: 10/05/2023
Date Signed: 10/05/2023 03:48:53 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/10/2023 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230810101047
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:
10/05/2023
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH: Carmenita Bernardo and Cheryl JacksonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Client had bruises while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegation. LPA met with Carmenita Bernardo and discussed the purpose of today's visit. Cheryl Jackson arrived and assisted with this visit.

On 08/17/23, LPA Irra conducted the initial investigation visit. During this visit, LPA obtained copies of the staff and client rosters. LPA reviewed file for C-1 and obtained copies of relevant documentation. LPA interviewed Staff #1 (S-1) through Staff #3 (S-3) and Frank D. Lanterman Regional Center Quality Assurance representative. Note: C-1 is no longer residing at this facility and is non-verbal.

During this invesgation, LPA also interviewed C-2. LPA attempted to interview C-3 and C-4 and was unable to interview as both are non-verbal.

Refer to LIC 9099C for the continuation of this report.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20230810101047
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/05/2023
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
Allegation: Client had bruises while in care. Staff interviews revealed that C-1 may have developed the bruising due to an incident that occurred on 08/04/23 in which C-1 was assisting C-2 with tying C-2's shoes and lost the balance and fell forward bracing C-1's arms. Per staff interviews, staff conduct visual body checks on all clients prior to leaving to day program and returning from day program. Interviewed staff did not see any bruises on C-1. LPA interviewed C-2 and confirmed the 08/04/23 incident. LPA also interviewed Frank D. Lanterman Regional Center Quality Assurance representative and was informed that their investigation results were "inconclusive". Interviews do not corroborate this allegation.

Based on record review and interviews conducted the findings indicate, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview conducted, appeal rights and a copy of this report was provided to Cheryl Jackson.

Note: LPA was experiencing technical difficulties during this visit. Report will be emailed to Ms. Jackson (Administrator).
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2