331880624-3-15-2023-18-AS-JESL-CQD2P3-20230328173340

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880624
Report Date: 03/15/2023
Date Signed: 03/15/2023 04:11:18 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/03/2020 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200903115604

FACILITY NAME:	GRACE HOME ATHENA		FACILITY NUMBER:	331880624
ADMINISTRATOR:	HAHN, JENNIFER		FACILITY TYPE:	740
ADDRESS:	35591 ATHENA CT		TELEPHONE:	(714) 814-4287
CITY:	WINCHESTER	STATE: CA	ZIP CODE:	92596
CAPACITY:	6	CENSUS: 5	DATE:	03/15/2023
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Jennnifer Hahn, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility failed to properly supervise resident that led to resident sustaining bruising
Facility failed to meet the resident hygiene needs

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Javina George and Janira Arreola arrived at the facility and met with Administrator Jennifer Hahn who was not available to physically come to the facility but was available via telephone to discuss and provide findings to the allegation noted above.

On September 3, 2020, Regional Office received complaint allegation(s) Resident #1 (R1) was admitted to hospital with bruising under both eyes. It was alleged that R1 had made statements that someone at the facility had physically assaulted R1, resulting on R1 sustaining bruising under both eyes. It was further alleged an unknown staff pushed R1 off the bed and slammed R1 against the wall several weeks prior to receiving the complaint. The department requested facility documentation, interviewed staff and requested hospital documentation. LPA found that on July 18, 2020 around 10:35 pm, indicated that R1 did in fact sustained an unwitnessed fall. Resident was not taken for medical attention due to R1 not complaining of any pain. On July 27, 2020, R1 would complaint of back pain and a telehealth visit with primary Doctor was completed on the same date. Doctor ordered X-Ray to investigate the pain.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200903115604

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GRACE HOME ATHENA	FACILITY NUMBER: 331880624
	VISIT DATE: 03/15/2023

NARRATIVE

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On August 13, 2020 X-Ray would reveal that R1 had Arthritis in R1s compression fracture in R1s back as a result of osteoporosis that was diagnosed on 2012. Although, it is undetermined if the facility was providing proper care and supervision during the time of fall. At this time, there is no evidence to corroborate that the facility failed to properly supervise resident that led to resident sustaining bruising. LPA was unable to find evidence that could assist in the dismissal of said allegations, as such, the allegation is thereby found to be UNSUBSTANTIATED.

Allegation: Facility failed to meet the resident's hygiene needs
On September 3, 2020, Regional Office received complaint allegation(s) Resident #1 (R1) that hygiene needs were not being provided by facility. The Department requested facility documentation, interviewed staff and requested hospital documentation. LPA found the facility provided accountability shower logs that showed R1 being bathed twice a week Tuesday and Friday since July to September 2020. Hospital Records reviewed did not re mediate concerns for un met needs in reference to hygiene.

At this time, there is no evidence to corroborate that the Facility failed to meet the resident’s hygiene needs. LPA was unable to find evidence that could assist in the allegations, as such, the allegation is thereby found to be UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with Jennifer Hahn via telephone and the documents provided were explained and a copy was provided during this visit.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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