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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802543
Report Date: 03/10/2025
Date Signed: 03/10/2025 05:22:02 PM

Document Has Been Signed on 03/10/2025 05:22 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:ATHERTON BAPTIST HOMESFACILITY NUMBER:
197802543
ADMINISTRATOR/
DIRECTOR:		ANGELA LEEFACILITY TYPE:
741
ADDRESS:214 SOUTH ATLANTIC BLVD.TELEPHONE:
(626) 289-4178
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY: 518CENSUS: 28DATE:
03/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:59 PM
MET WITH:Ruth Diehl, Assistant DirectorTIME VISIT/
INSPECTION COMPLETED:
05:22 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Alberto Lopez and Sakinah Madyun conducted an unannounced required annual inspection. LPA met with Assistant Director Ruth Diehl and explained the purpose of the visit. The facility is licensed as a Continuing Care Residential Community (RCFE-CCRC) to serve 518 residents, 60 years and above, of which 259 may be non-ambulatory. The hospice waiver is approved for 10 residents. There are currently 31 Assisted Living residents, 3 residents in the Memory Care unit, 66 residents in Skilled Nursing, and 254 residents in Independent Living.

LPAs toured the community with the Assistant director for the Assisted Living and Memory Care units, in addition to some of the common areas of the facility. The Assisted Living unit and Memory Care unit are detached from the main building. The Assisted Living unit consists of 32 individual apartments with their own bathrooms and a shared dining area. The Memory Care unit consists of 4 bedrooms, one TV room, 1 full bathroom and ½ bathroom, living room, dining room, small visiting room and kitchen. There is an alert system installed at all the doors.

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and have an infection Control Plan at facility.

Operational Requirements: The facility does accept patients with dementia. There 0 bedridden residents residing at the facility. The facility has enough liability insurance covering injury to residents and guest.

(continued on 809C)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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 03/10/2025 05:22 PM - It Cannot Be Edited


Created By: Alberto Lopez On 03/10/2025 at 05:08 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: ATHERTON BAPTIST HOMES
FACILITY NUMBER: 197802543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

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 cleaning solutions were accessible to residents in laundry room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
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Licensee locked the cleaning solutions during visit. ****no further action required****
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:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/10/2025 05:22 PM - It Cannot Be Edited


Created By: Alberto Lopez On 03/10/2025 at 05:08 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: ATHERTON BAPTIST HOMES
FACILITY NUMBER: 197802543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors.

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. Room 27 did not have a Slip-resistant mat which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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Licensee will purchase anti-slip mat for room 27 and send proof to LPA.
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:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


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: ATHERTON BAPTIST HOMES
FACILITY NUMBER: 197802543
VISIT DATE: 03/10/2025
NARRATIVE
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(continued from 809)

Physical Plant & Environment Safety: There is a pool on the premises, and it is secured as required. Facility has operable smoke and carbon monoxide detectors located in each room and hallways. Knives were locked and inaccessible to residents. Cleaning solutions were not locked in the common laundry area and accessible to residents. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in random resident’s bathrooms and laundry room and were measured between 107.6 -112.4 degrees F which is within required range of 105-120 degrees F. Skid mat was missing in room #27

Deficiencies cited on 809D, exit interview conducted and copy of report and appeal rights provided.

Due to time constraints, LPA will return another day to complete annual inspection.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
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