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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880624
Report Date: 08/19/2026
Date Signed: 08/19/2026 01:50:31 PM

Document Has Been Signed on 08/19/2026 01:50 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GRACE HOME ATHENAFACILITY NUMBER:
331880624
ADMINISTRATOR/
DIRECTOR:		HAHN, JENNIFERFACILITY TYPE:
740
ADDRESS:35591 ATHENA CTTELEPHONE:
(714) 814-4287
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 6CENSUS: 6DATE:
08/19/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator Jennifer HahnTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Andrew Martinez made an unannounced visit to the facility for the purpose of conducting the required comprehensive annual inspection. LPA met with staff members Leticia Villaverde and Seriminar Berutu and was granted entry to the facility. At time of the visit (2) staff and (6) residents were present. Administrator Jennifer Hahn was contacted and informed of the LPA's arrival; administrator arrived shortly after. LPA Martinez explained the purpose of the visit to Administrator Jennifer Hahn.

The facility is a single story (5) resident bedroom, (4) bathroom home with attached (3) car garages. There is a kitchen, dining room, great room, laundry room, and staff bedroom. The facility is the Residential Care Facility for the Elderly (RCFE), licensed for a capacity of (6) bedridden residents with a hospice waiver for (6), and current census of (6).

LPA was accompanied by 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 observed no obstructions to indoor and outdoor passageways. The facility maintained comfortable temperatures between 75 and 77 degrees Fahrenheit (F). LPA inspected resident bedrooms; all equipped with the necessary furniture (e.g., mattresses, lamps, chairs, storage space) and sufficient lighting per regulation. LPA observed that bathrooms were clean, and all bathroom fixtures and equipment were operating appropriately. LPA observed grab bars and non-skid mat in the resident bathrooms. LPA observed sufficient furniture/seating to accommodate indoor and outdoor activities for residents in care and guests. LPA measured hot water temperature to be at 110.1 degrees F. The facility is equipped with operating combination smoke alarms and carbon monoxide detectors.


*** Continuation in LIC 809-C ***
Karen Clemons
Andrew Martinez
DATE: 08/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2026
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 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GRACE HOME ATHENA
FACILITY NUMBER: 331880624
VISIT DATE: 08/19/2026
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Physical Plant continued: Postings such as personal rights, the CCLD complaint poster, Ombudsman poster, labor laws, facility sketch and license, theft & loss policy, administrator's certificate, and Emergency Disaster plan were all posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to residents. There are designated storage spaces for residents and staff files, and locked cabinets for storing residents’ medications. LPA observed (1) fireplace located in the facility's great room inaccessible to residents in care. No pools or other bodies of water were observed on property.

Food Service: There was seven (7) days non-perishable and three (3) days perishable food supply observed at the facility. Food preparation surfaces are kept clean and there is a sufficient amount of tableware (e.g. plates, cups, utensils, etc.) to accommodate residents in care.

Care & Supervision: LPA observed the facility's current Personnel Report LIC 500 showing a sufficient number of staff scheduled to provide twenty-four hour supervision to the number of residents in care.

Record Review: LPA reviewed (3) completed resident files for admission agreements, updated physician reports, and pre-placement appraisals, as well as their Medications Administration Record (MAR) showing no errors/issues. LPA reviewed three (3) completed staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings with tuberculosis (TB) test results. Disaster/earthquake/fire drills were observed to be conducted quarterly on a shift-rotational basis.

Based on today's visit, no deficiencies were observed per Title 22 California Code of Regulations CCR.

An exit interview was conducted where this Facility Evaluation Report (LIC 809, LIC 809-C) was discussed, and a copy was provided to Administrator Jennifer Hahn.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Andrew Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2026
LIC809 (FAS) - (06/04)
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