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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880624
Report Date: 07/28/2021
Date Signed: 09/21/2021 03:18:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GRACE HOME ATHENAFACILITY NUMBER:
331880624
ADMINISTRATOR:HAHN, JENNIFERFACILITY TYPE:
740
ADDRESS:35591 ATHENA CTTELEPHONE:
(714) 814-4287
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY:6CENSUS: DATE:
07/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jennifer HahnTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced annual inspection. LPA Prieto met with Jennifer Hahn. The home is licensed for 6 non ambulatory residents, 6 of which are bedridden .

The home is a six (6) bedroom, four (4) bath home with a living room, dining room and kitchen. All bedrooms are furnished with bed, night stand, dresser and chair. Bedrooms have adequate lighting for residents’ use. The facility currently has linens, towels and a sufficient amount of hygiene products for residents. The kitchen was observed clean and orderly. The backyard was observed to be fully fenced with an unlocked gate and has shaded area with table and chairs for client’s comfort while sitting outside. Staff and resident files are locked and secured. Medications are locked and in a secured location.

During the visit LPA discussed infection control procedures and practices with Jennifer Hahn. The home appeared to be in compliance and no deficiencies were observed or cited.

An exit interview was conducted and a copy of this report was reviewed with and provided to Ms Hahn
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
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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