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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601505
Report Date: 02/13/2023
Date Signed: 02/13/2023 12:18:41 PM

Document Has Been Signed on 02/13/2023 12:18 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 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:
02/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Acting Administrator, Monique JordanTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA was allowed entry into this home by Gema Garcia, Direct Support Professional/DSP and discussed the purpose of today's visit. The acting Administrator, Monique Jordan arrived at 10:45am and assisted LPA with the inspection. The facility is approved to serve Developmentally Disabled Adults ages 18 to 59 years old, ambulatory only. Facility is vendorized by Frank D. Lanterman. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and PPE supplies. This 2-story home contains three (3) bedrooms, two (2) bathrooms, office, a living room, kitchen, dining area, sitting area, activity area, backyard, and detached garage.

The following was observed/inspected:
  • The facility had a universal entrance screening area including a thermometer, PPE supplies, screening logs, and sign-in sheet.
  • LPA observed that Staff/DSP was not wearing a face covering/mask and did not conduct a routine covid screening to the LPA upon entry and had to be prompted.
  • There was no COVID-19 signage placed observed at the entrance and in several areas of the facility.
  • Facility maintained a 30-day supply of PPE located in the supply closet in the office.
  • The kitchen was inspected. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All the appliances are clean and working properly.
  • The laundry room is inside the home, next to the kitchen area. It is clean and has all cleaning supplies locked in a cabinet and inaccessible to clients.
  • Cleaning solutions and sharps were locked in a cabinet in the kitchen area and inaccessible to clients.



*****CONTINUED ON LIC 809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2023
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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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 ANNEX
FACILITY NUMBER: 198601505
VISIT DATE: 02/13/2023
NARRATIVE
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  • Water temperature was measured in kitchen and bathrooms. Hot water in the kitchen read 105.8 deg F, Bathroom #1 read 105.2 deg F and bathroom #2 read 105.9 deg F and all areas measured within the required 105 - 120 degrees.
  • Clients bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, night stand, light, chair and sufficient closet space.
  • Bathrooms have the required grabs bars and contained hygiene supplies including liquid soap, air hand dryer and toilet paper.
  • Medications were locked, centrally stored, and given as prescribed. Clients' medications were reviewed to confirm medication is given as prescribed and is documented properly.
  • The common areas such as activity room and dining room are clean and have the required furniture. Furniture and group activities were spaced to encourage physical distancing.
  • The backyard has sitting area but there was no shaded area.
  • LPA observed the screen on the window by the kitchen
  • The backyard has been designated as the visitor area during the COVID-19 pandemic.
  • There are two (2) fire extinguishers in the facility, located in the kitchen and the hallway upstairs. Fire extinguisher #1 was observed to be fully charged and last serviced on 9/2022 and fire extinguisher #2 was last serviced on 7/18/2022.
  • There were no cameras or bodies of water observed in the facility.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • Staff and clients files were not reviewed during the visit.
  • Licensee, Ann Hamilton was listed as the Administrator for the facility. A copy of her Administrator certificate was provided and expires on 11/01/2024.
  • Acting Administrator, Monique Jordan' Administrator certificate expires on 4/6/2023.
  • A copy of the Facility's Surety Bond was provided to LPA.

Pursuant to Title 22, deficiencies were cited on the attached 809-D. An exit interview was conducted, and a copy of this report and appeal rights were provided to the Acting Administrator, Monique R. Jordan.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/13/2023 12:18 PM - It Cannot Be Edited


Created By: Bennette Pena On 02/13/2023 at 11:46 AM
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: 02/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85095.5(c)(1)(F)
85095.5 Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022.
(1) The Infection Control Plan shall include all of the following:
(F) Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the Administrator did not comply with the section cited above in which LPA was greeted by Staff/DSP inside the facility (by the front door) and Staff/DSP was observed not wearing a face covering/mask, while working inside the facility. Additionally, Staff/DSP did not conduct routine covid screening to the LPA upon entry and had to be prompted which posed an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 02/14/2023
Plan of Correction
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Although the staff/DSP wore a face covering/mask when prompted, LPA required the Administrator to ensure that all facility staff are following Pasadena Public Health and CCLD requirements by conducting an in-service training with all staff on the importance of wearing a face covering/mask and also on the importance of COVID screening for all visitors, staff and clients. Administrator will submit a copy of the sign-in sheet of all attendees along with the topics covered during the in-service training to CCL by the POC due date.

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: 02/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/13/2023 12:18 PM - It Cannot Be Edited


Created By: Bennette Pena On 02/13/2023 at 11:59 AM
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: 02/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the Administrator did not comply with the section cited above in that the front door screen and the window screen mesh by the kitchen area were broken and need to be repaired which poses/posed a potential health, safety or personal rights risk toclients in care.
POC Due Date: 02/20/2023
Plan of Correction
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Administrator will submit photos of the repaired front door/window screen, as well as receipts/service reports to CCL by POC due date.
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: 02/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2023


LIC809 (FAS) - (06/04)
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