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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530087
Report Date: 03/04/2026
Date Signed: 03/04/2026 02:48:44 PM

Document Has Been Signed on 03/04/2026 02:48 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 HOMEFACILITY NUMBER:
365530087
ADMINISTRATOR/
DIRECTOR:		MAYRA LOPEZFACILITY TYPE:
735
ADDRESS:11516 THIRD AVETELEPHONE:
(909) 565-5735
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 4CENSUS: 3DATE:
03/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Fontene WilsonTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA was granted entry to the facility and met with House Manager Fontene Wilson to discuss the purpose of the visit. The facility is an Adult Residential facility with a license capacity of (4) and a current census (3). LPA conducted an overall inspection, which included, but was not limited to, the following:

Operation/Physical Plant: The facility is maintained at a temperature of 74 degrees Fahrenheit. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor activity space for clients in care. Outdoor activity space is shaded and enclosed with latching gate. Client bedrooms were equipped with beds, bed linen, night stands, storage space and lighting. Client bathroom equipment were fully operating and showers were equipped with non-skid material. The hot water in client bathrooms tested at 107 degrees Fahrenheit. The facility is equipped with activity supplies, operating carbon monoxide/smoke alarms, fire extinguisher, laundry equipment, hallway lighting, emergency supplies and water. The facility has posted: Community Care Licensing complaint poster, facility sketch, facility license, menu, emergency telephone numbers and house rules. Cleaning supplies and sharps were kept locked. There was a designated space for client/staff files. Facility staff maintains an infection control plan, client registry, liability insurance and emergency/disaster plan.

Food Service: The facility’s dining and kitchen areas are maintained clean. The facility has sufficient supply of non-perishable and perishable food for number of clients in care.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2026
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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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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Document Has Been Signed on 03/04/2026 02:48 PM - It Cannot Be Edited


Created By: Magda Malcore On 03/04/2026 at 02:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ATHENA HOME
FACILITY NUMBER: 365530087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
80075(b)(5)(B)
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client 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 client with self-administration, provided all of the following requirements are met: (B) 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
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Based on LPA observations, the licensee did not comply with the section cited above by staff not administering client medications according to physician's new medication cycle date; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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The Licensee/House Manager has agreed to retrain staff in medication management and provide documentation of training to the licensing agency by 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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2026


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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ATHENA HOME
FACILITY NUMBER: 365530087
VISIT DATE: 03/04/2026
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Health Related Services: The facility maintains a first aid kit with manual. LPA reviewed medications for three (3) clients. LPA observed PM medications for two (2) clients were not given according to physician's directions and label instructions. Staff did not administer clients pm medications in accordance with the start of medication cycle date and started/administered clients medications on the an incorrect date.

Personnel/Client Records: Staff records were reviewed for health screenings, criminal record clearances, employment history, orientation, and first aid/CPR training certifications and CPI certifications. Client records were reviewed for admission agreements, medical assessments, needs and service plans, and personal/incidental logs.

During today's visit, a deficiency was cited in accordance with Title 22, Division 6 of the California Code of Regulations.

An exit interview was conducted. Copies of reports LIC809/LIC809C/LIC809D and appeal rights were provided to The House Manager.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2026
LIC809 (FAS) - (06/04)
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