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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601505
Report Date: 06/07/2024
Date Signed: 06/07/2024 01:14:42 PM

Document Has Been Signed on 06/07/2024 01:14 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/
DIRECTOR:		HAMILTON, ANNFACILITY TYPE:
735
ADDRESS:853 N HOLLISTON AVETELEPHONE:
(626) 794-4103
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 6DATE:
06/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Monique Jordan - AdmiinistratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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
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 Gema Pinto De Garcia, Direct Support Professional I & II (DSP I & II) and explained the purpose of the visit. At 10:00am, Monique Jordan, Administrator arrived and assisted LPA with the inspection. The facility is licensed to care for (6) 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 (3) client bedrooms, (2) full bathrooms, office/storage supplies room, a living room, activity area next to the dining area, kitchen, breakfast nook, game room upstairs, basement, backyard, and detached garage. Currently, there are (6) 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. Bathrooms contained hygiene supplies including liquid soap and toilet paper. Kitchen was inspected and LPA observed that one of the kitchen drawer door was broken. The door through the basement did not have a secured lock. And the glass panel on the game room door upstairs is broken. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and area provides outdoor furniture, however, there was no patio umbrella or any type of shade provided. Kitchen knives, sharps objects, cleaning supplies, and toxic substances are locked in the cabinet downstairs and inaccessible to clients. LPA observed disinfectants and cleaning supplies stored in an unlocked cabinet in the upstairs bathroom. There are (2) fire extinguishers observed to be fully charged and was last serviced on 7/21/2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Facility does not have a video camera monitor system. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. At 9:35am, hot water supply measured at 110.6 deg F in bathroom #1 and 109.6 deg F in bathroom #2.
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. Liability Insurance policy is valid and will expire on 10/17/2024. Surety Bond Insurance with bond amount of $5000 is valid and will expire on 12/01/2024. Last Fire Drill was conducted on 03/21/2024 and according to the Administrator, emergency drills are conducted on a quarterly basis. *****REPORT CONTINUED ON LIC809-C****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
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: 06/07/2024
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
Staffing: A total of (7) staff members including the 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 three (3) 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 a valid 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 (1) client has a cell phone and (3) have their own tablet/IPad. LPA conducted (1) client interview as the other (5) clients are out in the Day Program.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C3. 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. Face Sheets on a few clients need to be updated.
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. Pesticides and cleaning supplies are kept away from the food preparation areas. Plates, cups and utensils are kept cleaned and stored properly.
Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for C1-C6 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA observed that one of the medications being administered to Client #1 did not have a label and Administrator cannot provide a Physician's order.
Incidental Medical Services: Per the 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 Violations issued. Exit interview, appeals rights and a copy of this report was provided to the Administrator, Monique Jordan.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 06/07/2024 01:14 PM - It Cannot Be Edited


Created By: Bennette Pena On 06/07/2024 at 12:00 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: 06/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the Administrator did not comply with the section cited above in which disinfectants and cleaning supplies were stored in an unlocked cabinet in the upstairs bathroom which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 06/07/2024
Plan of Correction
1
2
3
4
Administrator and staff removed all the disinfectants and cleaning supplies from the bathroom and stored the items in a locked cabinet downstairs. ***DEFICIENCY CLEARED DURING THE VISIT.***
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 06/07/2024 01:14 PM - It Cannot Be Edited


Created By: Bennette Pena On 06/07/2024 at 12:00 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: 06/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(D)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, record review, the Administrator did not comply with the section cited above in which one of the medications being administered to Client #1 did not have a label and Administrator cannot provide a Physician's order which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 06/10/2024
Plan of Correction
1
2
3
4
Administrator shall ensure that all clients' medications have labels and physician's order. Administrator will send copy of the physician's order for Client #1's medication Imbrovica tab 420 mg and photo of the medication with proper label to CCL/LPA by POC due date.

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: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 06/07/2024 01:14 PM - It Cannot Be Edited


Created By: Bennette Pena On 06/07/2024 at 12:00 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: 06/07/2024

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
1
2
3
4
Based on observation, the Administrator did not comply with the section cited above in which one of the kitchen drawer front is broken which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 06/14/2024
Plan of Correction
1
2
3
4
Administrator will send photos that the kitchen drawer front has been fixed to CCL/LPA by POC due date.
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the Administrator did not comply with the section cited above in that there is no patio umbrella or shaded area provided in the backyard which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 06/14/2024
Plan of Correction
1
2
3
4
Administrator to send receipt of the patio umbrella and photo that it has been installed to CCL/LPA by POC due date.
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: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7