198601502-1-24-2025-28-AS-RORN-DE3U48-20250220141442

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601502
Report Date: 01/24/2025
Date Signed: 01/24/2025 12:02:44 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
11/22/2024 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20241122165856

FACILITY NAME:	RAYMOND HOUSE		FACILITY NUMBER:	198601502
ADMINISTRATOR:	HAMILTON, DAVID		FACILITY TYPE:	735
ADDRESS:	872 N RAYMOND AVE		TELEPHONE:	(626) 792-8813
CITY:	PASADENA	STATE: CA	ZIP CODE:	91103
CAPACITY:	22	CENSUS: 9	DATE:	01/24/2025
		UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Phillip Jordan - Facility Supervisor		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff caused an injury to a resident in care.
Staff improperly restrained a resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit to continue investigating the above allegations. LPA met with Carmelita Bernardo, DSP and explained the purpose of the visit. At 9:32am, Phillip Jordan, Facility Supervisor arrived and discussed the purpose of today's visit.
The investigation consisted of the following: On 11/25/2024, LPA conducted a tour of the facility's common areas including client's bedrooms and obtained copies of the Client & Staff Rosters, Client #1 (C1) files such as; Identification & Emergency Information (Face sheet), Physician's Report (08/01/2024), Admission Agreement (08/01/2024), Pre-Placement Appraisal, Client Personal Rights, Care/daily notes (Aug 2024-Oct 2024), Unusual Incident/Injury Report (10/30/2024) and Medication Administration Records (Aug 2024-Nov 2024). LPA interviewed Staff #1 (S1) - Staff #3 (S3).
During today’s visit, LPA conducted a tour of the facility, obtained copies of the Client & Staff Rosters, and C1's Behavior Report (09/01/2024). Prior to the visit, LPA telephonically interviewed Staff #4 (S4) – Staff #6 (S6) and Client #2 (C2) – Client #3 (C3). LPA attempted to speak with Client #1 (C1) but unsuccessful as calls were not returned.
*****CONTINUED ON LIC9099-C*****

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/24/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20241122165856

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: 01/24/2025

NARRATIVE

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The investigation revealed the following:

In regards to the allegation: “Staff caused an injury to a resident in care.” It is alleged that S1 pushed C1 against the wall that caused bruising to C1’s left arm, swollen shoulder, and elbow. (6) out of (6) staff interviewed denied the allegation. All staff interviewed stated that they never pushed anyone against the wall nor caused any bruising to C1 or any clients. S1 stated that on 10/30/2024, S1 arrived at the facility after receiving a report from S6 that C1 was experiencing a behavioral episode and was highly agitated. S1 indicated that C1 had blocked the door with items from his bedroom to stop staff from entering. Interviewed staff who were present during the incident revealed that they all attempted to verbally redirect C1 while respecting his personal space. As C1 exited his room, C1 tried to grab S6 and S1 intervened by positioning himself in front of C1. C1 then pushed S1 to clear his way and S1 hit the wall. Both S1 and C1 lost their balance and fell to the floor. Subsequently, C1 walked outside and sat in the porch area. At that moment, S1 continued to redirect C1 and when S4 arrived, he also attempted to redirect C1. Interviewed staff members stated that C1 did not sustain harm or injuries. (3) of (3) clients interviewed denied the allegation. Interviewed clients indicated that the staff treat them with respect, and they all feel safe at the facility. Clients also indicated that none of the staff had harmed or injured them or other clients in the facility. Based on files reviewed, Frank D. Lanterman Regional center had completed their investigation regarding this incident and determined the allegation to be unsubstantiated. Staff interviews, client interviews and reviewed documentation do not corroborate this allegation.

***CONTINUED ON LIC9099-C***

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/24/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20241122165856

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: 01/24/2025

NARRATIVE

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In regards to the allegation: “Staff improperly restrained a resident in care.” It is alleged that C1 fell down to the ground when the staff placed their knee into C1’s stomach, preventing C1 from getting up. (6) out of (6) staff interviewed denied the allegation. Interviewed staff indicated that it was C1 who became aggressive towards staff, was yelling and throwing objects. Interviewed staff stated that they verbally redirected C1 in an effort to ensure safety for both C1 and themselves. Interviewed staff stated that they did not engage in any form of physical restraint. C1 has a history of physical and verbal aggression, emotional outbursts, and wandering off. Interview with B1 revealed that C1 has a history of fabricating stories, seeing things, and avoiding contact with females, and does not respond to directions from female staff. All staff interviewed indicated that they have never improperly restrained C1 or any other clients. Interviews conducted with staff members all indicated that interventions applied to C1 have all been part of C1's approved behavior support plan. Interviewed staff stated that no harm was inflicted on C1 and that C1's behavior support plan was followed. LPA attempted to interview C1, however calls were not returned. (3) out of (3) clients interviewed cannot corroborate the allegation. Interviewed clients stated that they were never restrained nor have seen any other clients being improperly restrained. Interviewed clients stated that they feel safe in the facility. Therefore, there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report was provided to Phillip Jordan, Facility Supervisor.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/24/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025

LIC9099 (FAS) - (06/04)

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