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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601505
Report Date: 07/02/2026
Date Signed: 07/02/2026 12:56:04 PM

Document Has Been Signed on 07/02/2026 12:56 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
MONTEREY PARK ASC, 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:
07/02/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Monique Jordan, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual visit today. LPA met with Gema Patricia Garcia, Direct Support Staff, and the reason for the visit was explained. Monique Jordan, Administrator, arrived thereafter and continued to facilitate the visit.

The facility is licensed to serve (6) developmentally disabled adults ages 18 to 50 years of age, ambulatory only. Clients in care receive services through Frank D. Lanterman Regional Center.

The two-story home is in a residential area of Pasadena. The home consists of the following:

First floor has a living room, (2) dining rooms, kitchen, laundry area, (1) full bathroom, (1) client bedroom and staff office. Second floor has (2) client bedrooms, (1) full bathroom and activity room. The facility also has a front and backyard with patio area and detached garage.

The following was observed during today’s visit:

Facility is clean and walkways, passages and stairwell are free of debris and obstructions. Furniture in the living and dining room was observed in good repair and there is sufficient seating for clients. Client bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. However, dresser in bedroom #2 is missing a drawer handle. Light in bedroom #2 did not turn on during inspection. Light was tested by LPA and observed non-operational. Broken curtain rod was also observed in bedroom #2.

***Continues on LIC 809-C***

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/02/2026 12:56 PM - It Cannot Be Edited


Created By: Mayra Cota On 07/02/2026 at 11:53 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: 07/02/2026

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
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Based on observation, the licensee did not comply with the section cited above due to dresser in bedroom #2 is missing a drawer handle and a broken curtain rod was also observed in bedroom #2, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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Administrator will send LPA photos of the repairs by POC due date.
Type B
Section Cited
CCR
80088(d)
Fixtures, Furniture, Equipment, and Supplies
(d) The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the comfort and safety of all persons in the facility.

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 due to light in bedroom #2 not turning on during inspection. Light was tested by LPA and observed non-operational, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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Administrator will send LPA photos of the repairs 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.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/02/2026 12:56 PM - It Cannot Be Edited


Created By: Mayra Cota On 07/02/2026 at 11:53 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: 07/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above due to wall above faucets in hand washing sinks in bathrooms #1 and #2 have chipping plaster. Also observed, a missing tile in shower in #2 has exposed splintered wood and nails. Bathtub in bathroom #1 and shower in bathroom #2 do not have anti-slip mats. The forementioned deficiences poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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Administrator will send LPA photos of the repairs 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.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2026


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: RAYMOND HOUSE ANNEX
FACILITY NUMBER: 198601505
VISIT DATE: 07/02/2026
NARRATIVE
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Both bathrooms were inspected and observed clean and sanitary. However, wall above faucets in hand washing sinks in bathrooms #1 and #2 have chipping plaster. Also observed, a missing tile in shower in #2 has exposed splintered wood and nails. Bathtub in bathroom #1 and shower in bathroom #2 do not have anti-slip mats. The water temperature was tested in both bathrooms and measured within the required compliance range of 105 - 120 degrees F. Sufficient personal hygiene supplies for clients are available for use. Laundry room appliances observed to be working properly, and detergents are kept locked in a cabinet.

Kitchen was observed clean and sanitary. Appliances are also clean and working properly. The home has sufficient two-day perishable and seven-day non-perishable food supply. Knives and other sharps are kept locked. Secondary dining room has sufficient seating and furniture is in good repair.

The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area accessible to clients, located in the backyard. Patio furniture in the back yard was observed clean and in good repair. Garden is maintained and passageways and exits are free of obstruction. Garage is kept locked and inaccessible to clients.

Smoke detectors were observed throughout the facility and were tested and observed to be working properly. Carbon monoxide detector located on the second floor was also tested and was observed to be working properly. The home is equipped with two fire extinguishers, (1) located by the kitchen and (1) on the second-floor hallway. Both were observed charged and were last inspected on 7/10/2025. Last fire/safety drill was conducted on 5/26/2026. Fireplace in the living room is covered and is inaccessible to clients.

Six (6) client and (3) staff files were reviewed. Files have the required documentation in place. Medication is kept centrally stored, locked and inaccessible to clients. Medication review was also conducted for (3) clients and was observed to be administered and per physician's orders.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies were noted and citations issued during today's visit. A Technical Advisory Note was also provided. Exit interview was held with Monique Jordan, Administrator, and a copy of the report, LIC 809-D, and Appeal Rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026
LIC809 (FAS) - (06/04)
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