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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802543
Report Date: 03/17/2025
Date Signed: 03/17/2025 05:09:51 PM

Document Has Been Signed on 03/17/2025 05:09 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:
03/17/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:18 PM
MET WITH:Daniella Doromal, Director of Assisted Living TIME VISIT/
INSPECTION COMPLETED:
05:14 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) Alberto Lopez made subsequent unannounced visit to complete the annual inspection started on 03/10/2025. LPA met with Director of Assisted Living Daniella Doromal and discussed the purpose of the visit.

Today LPA reviewed the following.

Staffing: There appears to be sufficient staffing at the facility. The Administrator's (Angela Lee) certificate expires 03/28/2025. Administrator retired unexpectedly and facility is in process of hiring new administrator. Proof of renewal Staff employed are all over the age of 18.
Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training and sufficient on-going training.
Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Identification & Emergency Information, Original Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. Some residents files need current Physicians reports.
Resident Rights-Information: The Complaint poster and Residents personal rights are posted by the main entry. Visitors can visit anytime.
Food Service: There are sufficient food supplies of 2-day perishable. Seven-day non-perishable in storage. The food is properly stored in the refrigerator to avoid cross contamination
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.

Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA reviewed 4 residents' medication, and all medication is administered according to doctor’s orders. However, some PRN medications are missing labels.

Disaster Preparedness: The facility has an Emergency Disaster Plan but requires updating.

Residents with Special Health Needs: The facility accepts and retains residents with special health needs. Two residents with special health needs resides at facility. The staff received training on appropriately caring for residents with special health needs.

Exit interview conducted with Director of Assisted Living Daniella Doromal copy of report, 809D and appeal rights provided along with one technical advisory.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2025
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 3
Document Has Been Signed on 03/17/2025 05:09 PM - It Cannot Be Edited


Created By: Alberto Lopez On 03/17/2025 at 04:42 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: 03/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation record review, the licensee did not comply with the section cited above. 1 of 4 resident's PRN did not have label which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
1
2
3
4
Administrator will obtained labels and send proof to LPA by 03/18/2025
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3