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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802543
Report Date: 03/06/2026
Date Signed: 03/06/2026 05:17:36 PM

Document Has Been Signed on 03/06/2026 05:17 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:ATHERTONFACILITY NUMBER:
197802543
ADMINISTRATOR/
DIRECTOR:		JOELLE E. MEDINAFACILITY TYPE:
741
ADDRESS:214 SOUTH ATLANTIC BLVD.TELEPHONE:
(626) 289-4178
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY: 518CENSUS: 26DATE:
03/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:53 AM
MET WITH:Joelle E Medina, Administrator TIME VISIT/
INSPECTION COMPLETED:
05:24 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced required annual inspection. LPA met with Administrator Joelle Medina 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 26 Assisted Living residents, including 14 in temporary Joselyn wing, 2 residents in the Memory Care unit, 60 residents in Skilled Nursing, and 254 residents in Independent Living.

LPAs toured the community with the Administrator 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, of which 19 are being remodeled and 14 residents are being temporary housed at Joselyn wing, 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. Currently there are two (2) resident residing in memory. There is an alert system installed on 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 has an infection Control Plan at facility.

Operational Requirements: The facility does accept patients with dementia. There are 0 bedridden residents residing at the facility. The facility has enough liability insurance covering injury to residents and guest. (continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2026
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 8
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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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
FACILITY NUMBER: 197802543
VISIT DATE: 03/06/2026
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 and central fire alarm that were all tested. The memory Care was missing carbon monoxide detectors. Facility staff promptly installed them during visit. Knives, cleaning solutions, and disinfectants are locked and inaccessible to residents. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the resident’s bathrooms and kitchen sink. The hot water temperature in the bathrooms was measured between 112.6-118.8 degrees F, which is within required range of 105-120 degrees F.

Staffing: There appears to be sufficient staffing at the facility. The administrator's (Joelle Medina) certificate expires, 06/11/2027 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 Physicians reports.

Resident Rights-Information: The Complaint poster and Residents personal rights are posted by the main entry. Visitors can visit anytime.

Incidental - Medical Dental: Some medications were missing from cart and some did not have labels. Most of the medications are administered as ordered.

Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.

Disaster Preparedness: The facility has an Emergency Disaster Plan but requires updating. Fire and disaster drills are conducted monthly. Last one was 3/02/2026 Facility will find additional evacuation location outside the immediate area and update Emergency Disaster plan.

Residents with Special Health Needs: The facility does not accept and retains residents with special health needs.

Exit interview conducted, deficiencies cited, technical advisories provided, 809D and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2026
LIC809 (FAS) - (06/04)
Page: 8 of 8
Document Has Been Signed on 03/06/2026 05:17 PM - It Cannot Be Edited


Created By: Alberto Lopez On 03/06/2026 at 04:53 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
FACILITY NUMBER: 197802543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. The memory care unit did not have carbon monoxide detectors which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2026
Plan of Correction
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Administrator had staff install four carbon monoxide detectors during visit. *****NO FURTHER ACTION REQUIRED***
Type B
Section Cited
CCR
87465(c)(1)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.

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. R1 had trazodne but was not on list of medications. R3 had no order for Centrum, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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Administrator will obtain doctor's orders for the medications and send proof to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Alberto Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2026 05:17 PM - It Cannot Be Edited


Created By: Alberto Lopez On 03/06/2026 at 04:53 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
FACILITY NUMBER: 197802543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) 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 resident'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
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Based on observation, the licensee did not comply with the section cited above. 3 of 4 residents did not have labels on some medications/.PRNs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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Administrator will obtain labels for all medications/PRNs 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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Alberto Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2026


LIC809 (FAS) - (06/04)
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