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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880624
Report Date: 03/15/2023
Date Signed: 03/15/2023 04:12:30 PM


Document Has Been Signed on 03/15/2023 04:12 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
CCLD Regional Office,
, CA



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: 5DATE:
03/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:19 PM
MET WITH:Caregiver Maria Elvira FranciscoTIME COMPLETED:
04:30 PM
NARRATIVE
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At 2:40pm Licensing Program Analysts (LPAs) Javina George and Janira Arreola made an unannounced visit to the facility to deliver findings for a complaint control number 18-AS-20200903115604.

LPAs George and Arreola were greeted by Caregiver Maria Elvira Fransisco. LPAs explained the purpose of the visit. The Administrator Jennifer Hahn was not available to physically come to the facility but was available via telephone. LPAs George and Arreola conducted a tour and observed the following:


Staff #1 (S1) was observed for to not be associated to the facility. LPA reviewed staff's criminal background clearance and did verify she has cleared fingerprint background clearance, but still does not have the transfer of clearance to be associated and to work in this facility.

A Civil Penalty of $100/day will apply for a total of $500 for five (5) days as interview evidence verifies that
The following violation is cited under Title 22 section 87355(e)(2). Deficiency cited.

In addition, at 2:50pm inside the closet in the master bedroom, there was a bed, sheets, two (2) pillows, a blanket, and identified items (make up bag, hygiene products, and a small black back pack belonging to S1. Deficiency was not cited, as this was corrected at the time of LPAs visit.

An exit interview was conducted and a copy of this report, 9099D,appeal rights, and Civil penalty assessment was reviewed via telephone with Administrator Jennifer, and provided to Caregiver Maria Elvira Francisco.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2023
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 2


Document Has Been Signed on 03/15/2023 04:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: GRACE HOME ATHENA
FACILITY NUMBER: 331880624

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/16/2023
Section Cited

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87355(e)(2) (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: S2 is cleared but not associated to the facility. This poses an immediate health safety or personal risk to persons in care.
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The licensee agrees to associate S1 in Guardian by 5 pm on the due date indicated.

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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2