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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601506
Report Date: 07/29/2023
Date Signed: 07/31/2023 09:14:03 AM

Document Has Been Signed on 07/31/2023 09:14 AM - 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:HARRIET HOUSE ANNEXFACILITY NUMBER:
198601506
ADMINISTRATOR:ANN HAMILTONFACILITY TYPE:
735
ADDRESS:916 CHESTERTELEPHONE:
(626) 791-9215
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 6DATE:
07/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Staff #1TIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Kimberly Ramirez attempted to conduct required annual inspection. LPA Ramirez asked S1 if any clients were aggressive in the home. S1 called Administrator Monique to inform her licensing was at the facility. LPA Ramirez observed Client #1 (C1) becoming agitated upon seeing LPA Ramirez in the facility. LPA Ramirez again asked Administrator Monique if any of the clients were aggressive in the home. Administrator Monique confirmed no clients pose an immediate threat. As LPA Ramirez was attempting to set up on the dining room table, C1 picked up a pink object and raised it above C1's head and made a motion as if C1 was going to throw the pink object at LPA Ramirez. C1 did this twice while LPA Ramirez was speaking with S1 in the dining room area. C1 began pacing back and forth from the dining room area to the kitchen then pace back into the living room. C1 then began to walk towards LPA Ramirez and stopped 5 ft away made a fist and swung C1's arm in the air as and made a kicking motion towards LPA Ramirez. S1 tried several times to redirect C1 to allow LPA Ramirez to continue the visit. LPA Ramirez observed C1 becoming more agitated and again walk towards LPA Ramirez and stop within in a few feet of LPA Ramirez and make swinging motions with fist and kicking motion with feet. Staff made multiple attempts to distract C1 and redirect her to the living room couch. C1 refused to go.

Due to LPA Ramirez's safety and they safety of the clients in care, LPA Ramirez will return to complete annual visit when clients are attending day program during the week. LPA Ramirez was unable to get signature on report but will email to Administrator Monique to sign on 7/29/23
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2023
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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