331880624-7-27-2024-56-AS-MBRN-D7KRK7-20240727130504

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880624
Report Date: 07/27/2024
Date Signed: 07/27/2024 01:05:11 PM

Document Has Been Signed on 07/27/2024 01:05 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

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: 4	DATE:	07/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:14 AM
MET WITH:	Licensee/Administrator Jennifer Hahn		TIME COMPLETED:	01:15 PM

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On 07/27/2024 at 09:14 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. At the time of the visit there were two (2) staff present, and four (4) residents present. Licensee/Administrator Jennifer Hahn was contacted and informed of the visit. Licensee/Administrator Hahn arrived during the visit. LPA Brown explained the purpose of the visit to Licensee/Administrator Hahn.

The facility is a six (6) bedroom, four (4) bathroom home with a kitchen/dining area, living room, activity room, laundry area and garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be bedridden. The facility has six (6) Hospice Waiver. The current census is four (4) residents. LPA Brown was accompanied by Staff #2 (S2) and Licensee/Administrator Hahn to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit (F). LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps and storage space. LPA Brown observed sufficient lightning. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms. During the tour of the facility, LPA Brown observed Resident #2 (R2), has half bed rails. Licensee/Administrator Hahn reported to LPA Brown that R2 does not have written order from their physician indicating the need for half bed rail for mobility. Deficiency will be issued.

***Continuation in LIC809C ***

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GRACE HOME ATHENA	FACILITY NUMBER: 331880624
	VISIT DATE: 07/27/2024

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LPA Brown observed sufficient furniture and lighting throughout the facility. Night lights were observed in the common hallway towards the residents' shared bathrooms. LPA Brown measured and observed the water temperatures in the bathroom to be at 110 degrees F. The facility is equipped with operating combined smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster, and the Emergency Disaster plan, Labor Laws were posted in a common area.

There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked. First Aid KIt and First Aid Guide/Book were also observed at the facility

Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility.

Care & Supervision: The facility has an administrator present during the visit. However, during the staff interview, two (2) of two (2) staff interviewed reported no staff works at night, awake and on duty as required for facility with dementia residents. Deficiency will be issued.

Record Review: LPA Brown reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. The files were complete with updated physician’s reports, admissions agreements, and preadmissions appraisals and needs and services plans. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA Brown observed that files reviewed were complete.

During the medication audit, LPA Brown observed two (2) medications of Resident #2 (R2) were not given according to physician's directions as evidenced of discrepancy observed on the quantity of R2's two (2) medications. Deficiency will be issued.

An exit interview was conducted where this report (LIC809), LIC809D, and Appeal Rights were discussed and provided to Licensee/Administrator Jennifer Hahn.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/27/2024 01:05 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GRACE HOME ATHENA	FACILITY NUMBER: 331880624
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

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: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that R2's medications were given according to R2's physician orders as evidenced of discrepancy oberved on the quantity of R2's two (2) medications which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87465(c)(2) and submit proof of staff training log to LPA Brown on Plan of Correction (POC) due date.

Type A

Section Cited

CCR

87705(c)(4)(A)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's a staff scheduled to work the night shift, awake and on duty as required for facility with dementia residents as evidenced of two (2) of two (2) staff interviewed reported that no staff's scheduled to work the night shift which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit an updated Personnel Report (LIC500) showing a staff scheduled to work the night shift, awake and on duty as required for facility with dementia residents to LPA Brown on POC due date.

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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/27/2024 01:05 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GRACE HOME ATHENA	FACILITY NUMBER: 331880624
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above allowing Resident #2 (R2) with half bed rail and not ensuring that there's a physician order indicating the need fof half bed rail for mobility for R2 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2024
	Plan of Correction
1 2 3 4	Licensee stated to obtain a written order from R2's physician indicating the need for half bed rail for mobility and submit proof to LPA Brown on Plan of Correction (POC) due date.

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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

LIC809 (FAS) - (06/04)

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