365530087-4-12-2023-56-AS-ACON-CQTTAH-20230412143334

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530087
Report Date: 04/12/2023
Date Signed: 04/12/2023 02:33:45 PM

Document Has Been Signed on 04/12/2023 02:33 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:	ATHENA HOME		FACILITY NUMBER:	365530087
ADMINISTRATOR:	LOPEZ, MAYRA		FACILITY TYPE:	735
ADDRESS:	11516 THIRD AVENUE		TELEPHONE:	(909) 565-5735
CITY:	HERPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY: 4		CENSUS: 0	DATE:	04/12/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Crystal Garcia, Administrator		TIME COMPLETED:	02:45 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, Amber Coleman, (LPA) conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPA met with Crystal Garcia, Administrator/Licensee and Myra Lopez, Licensee, introduced self and stated purpose of the visit. Initial Application submitted 3/23/23 to Centralized Applications Unit to operate an Adult Residential Facility (ARF) for a capacity of 4. Two (2) ambulatory and 2 non-ambulatory residents. Fire Clearance was granted 1/10/2023. LPA Coleman observed the following: Structure: Facility was a residence with 3 bedrooms, 2 bathrooms, kitchen, dining room, living room, and attached garage to be used as a staff office. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Bedrooms: Each resident bedroom will accommodate any non-ambulatory or ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm. Bathrooms: 2 bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Hand rails were observed near toilets and in showers/tubs. Water temperature measured by applicant and thermometer read by LPA at 107 to 122.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

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

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: ATHENA HOME	FACILITY NUMBER: 365530087
	VISIT DATE: 04/12/2023

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

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet and drawer. Cleaning solutions were designated for a securable cabinet under the sink. The sharp objects will be kept in a lockbox also under the sink cabinet. There was adequate room for food storage in the kitchens panty. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals. Laundry area with washer and dryer were located along the hallway. There are (2) cabinets above which are lockable. Laundry supplies have been designated to these cabinets. Also, houses a staff station with computer and cabinetry.
Living/Family room: The living room, located near the entrance of facility was safe and provides adequate seating and furnishings are in good repair.
Linens and Hygiene Supplies: An adequate supply of linens was available in the cabinets above the washer and dryer. Also in each resident room.
Yards/Outside: The backyard was contained a patio with adequate covered area for providing shade. There were no obstructions. There were no bodies of water observed anywhere on the property.
Hallway Closet: to be used for extra PPE and paper supplies.
Garage: Laundry detergents and cleaning solutions were secured behind a locked garage door in securable cabinets. Garage contains two staff stations and conference table. Observed to be organized and free of obstructions.
Emergency Phone Numbers, and Exit Plan: Let-Us-No poster, Ombudsman poster and rights to resident and family councils posters are posted throughout facility.

General items: The facility has smoke alarms and carbon monoxide detectors in each room and throughout facility.These were tested and found. Flashlights throughout the facility also double as flashlights; in the event of an emergency. Resident/Staff records storage space has been allocated to the garage which will be used as a staff office. LPA observed a facility phone and it was verified to be operational.
The following items need to be corrected before the facility can become licensed:
Doorknob to garage - change lock to make inaccessible.
Perimeter Gate of backyard to side entry - completion of gate and secure side entry way.
Caution Sign to be posted near kitchen sink and bathrooms for temperature of water.

Comp. III Completed, CARE Tool utilized

Applicant will notify LPA of completion of the above items and submit corrections to LPA.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2