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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601505
Report Date: 03/02/2022
Date Signed: 03/02/2022 04:35:53 PM

Document Has Been Signed on 03/02/2022 04:35 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 HOUSE ANNEXFACILITY NUMBER:
198601505
ADMINISTRATOR:HAMILTON, ANNFACILITY TYPE:
735
ADDRESS:853 N HOLLISTON AVETELEPHONE:
(626) 794-4103
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 6DATE:
03/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Yajaira Zayas, House SupervisorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the infection control domain. LPA arrived unannounced and met with the House Supervisor who assisted with the inspection. The purpose of the visit was explained. The facility is licensed for six (6) ambulatory Developmentally Disabled adults 18 to 59 years of age. There are currently 6 ambulatory clients residing at the home.

LPA toured the facility with the house supervisor and observed the following:
* The facility is a 2-story house with 3 bedrooms, 1 staff room, 1 activity room (upstairs), 2 bathrooms (one upstairs and one downstairs), living room, dining room, kitchen, laundry area, basement, and a detached garage. The spacious backyard consists of tables and chairs for client use. The clients' rooms have the required furniture. The facility is well maintained with no items obstructing the passageways. LPA observed signage throughout the facility and in the restrooms for hand washing hygiene. LPA recommended to add additional signage such as sneeze/cough etiquette at the home. Clients' and Staff temperature are taken daily and logged. PPE supplies for at least 30 days are observed. Food supplies for 2 day perishable and a week of non-perishable are also observed. Knives, cleaning solutions, and disinfectants are stored and locked making them inaccessible to clients. Smoke detectors are located in each room and the carbon monoxide detector is located in the downstair hallway. They were tested and operable. The fire extinguishers were last inspected on 7/13/2021. The medications are centrally stored and locked. LPA reviewed all 6 clients' medications and staff are administering them as prescribed. LPA tested the hot water temperature in bathroom #1 and #2, which measured at 128.1 and 124.7 degree F, respectively.

LPA provided a technical advisory for the N95 Fit Testing.

A deficiency was issued for the hot water temperature documented on the LIC809D. An exit interview was conducted and a copy of this report along with appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
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 03/02/2022 04:35 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 03/02/2022 at 04:11 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 ANNEX
FACILITY NUMBER: 198601505

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088 Furniture, Fixtures, 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 maintaining the hot water temperature within 105 - 120 degree Fahrenheit in both bathrooms, which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/03/2022
Plan of Correction
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The Administrator shall re-measure the temperature to ensure that the hot water is maintained between 105 - 120 degree F and submit proof to LPA by POC due date 3/3/22. The Administrator shall also continue testing the hot water temperature throughout the week to ensure it is maintained within range.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022


LIC809 (FAS) - (06/04)
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