<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880624
Report Date: 07/26/2023
Date Signed: 07/26/2023 02:03:11 PM


Document Has Been Signed on 07/26/2023 02:03 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
SAN BERNARDINO, 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: 5DATE:
07/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Rowena Sendron, CaregiverTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Amber Coleman arrived at the Grace Home - Athena Residential Care Facility for the Elderly made an unannounced required annual visit to the facility. Staff member, Rowena Sendron answered the door. LPA introduced self and stated purpose of the visit. LPA was granted entry and asked to sign in. Staff notified Administrator of LPA visit. Administrator, Jennifer Hahn.

The facility is a residential home; which includes 6 bedrooms, 4 bathrooms, attached garage, laundry room, dining room, living room and den. The facility is licensed to provide care for six (6) bedridden residents. LPA conducted 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 (CCL). There are no obstructions to any of the indoor and outdoor passageways. The facility maintained a comfortable temperature. LPA inspected resident bedrooms; and observed that they were equipped with furniture according to regulation. Such as: Bed with clean linens, night stands, storage space, and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were in functional condition. LPA tested the temperature from the bathroom faucet, which read within regulated range. The facility is equipped with operational smoke detectors and carbon monoxide alarms. Administrator reports the last fire/earthquake drill was conducted June 2023. Posters such as; the Personal Rights, Long Term Care Ombudsman and Evacuation Plan/Facility Sketch were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to the residents in care within the facility's laundry room. The facility maintains its resident and staff files in 2 secure file cabinets. Medications were locked and inaccessible to residents within the previously mentioned file cabinets. The facility was equipped with both emergency and first aid kits readily available for use. LPA notes overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GRACE HOME ATHENA
FACILITY NUMBER: 331880624
VISIT DATE: 07/26/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility offers a variety of food as noted on the posted monthly food menu. Dishes, cups, and utensils were also stored properly and sufficient in amount. Emergency food and water were also observed.
Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department and adequate training.
Record Review: LPA reviewed 2 resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 2 staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members.

Based on observations, no deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Licensee; signature acknowledges understanding and receipt of report.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5