415600995-9-27-2024-14-AS-JCAA-D9HUL2-20240927154002

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600995
Report Date: 09/27/2024
Date Signed: 09/27/2024 03:40:09 PM

Document Has Been Signed on 09/27/2024 03:40 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	ATHERTON GARDENS		FACILITY NUMBER:	415600995
ADMINISTRATOR:	HOVORKA, KIMBERLY		FACILITY TYPE:	740
ADDRESS:	471 SANTA CLARA AVE		TELEPHONE:	(650) 993-9313
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94061
CAPACITY:	6	CENSUS: 3	DATE:	09/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Kimberly Hovorka, Administrator and Lara Mlekush, Administrator/Caretaker		TIME COMPLETED:	03:45 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	On September 27, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 10:25 AM to conduct the unannounced Annual 1-year required inspection. LPA Calandra was greeted by Kimberly Hovorka, Administrator and explained the purpose of the visit. LPA Calandra toured the physical plant. This is a 1-story building with 4 bedrooms, 2 bathrooms, a living room, dining room, kitchen, activities room, front and backyards. No accessible bodies of water or hazards were observed. The facility has a swimming pool and hot tub but both are fenced off (fence is higher than 5 feet) and in-accessible to persons in care. All bedrooms had the required furniture and sufficient lighting. The facility bathrooms had the required grab bars and anti-skid floor mats. The facility's hot water temperature was measured within the required range of 105-120 degrees Fahrenheit. The facility's first aid kit had the required scissors, tweezers, current edition of the first aid manual approved by the American Red Cross, thermometer, bandages, sterile first aid dressings. The facility's fire and carbon monoxide detectors were observed to be in working order. The facility's fire extinguishers were observed to be fully charged and last checked on 11/3/2023. The facility also has night lights in place in hallways and throughout the home. The facility had the required 7 days of non perishables and 2 days of perishables. No food was expired. LPA Calandra observed 1 resident sleeping in their room, and 2 residents in the living room/activities room participating in an activity. All sharp objects, poisons, and cleaning supplies were observed to be locked and in-accessible to persons in care. LPA requested and received the following documents at the facility: -Current Liability Insurance -Current LIC 500 - Administrator's certificate for Kimberly Hovorka LPA Calandra reviewed 3 resident files and 2 staff files. All were observed to be complete. The facility does not handle cash resources for residents as of 9/27/2024.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ATHERTON GARDENS	FACILITY NUMBER: 415600995
	VISIT DATE: 09/27/2024

NARRATIVE

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A review of Centrally Stored Medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.

No deficiencies were cited during today's visit.

An exit interview was conducted. This report was reviewed with Kimberly Hovorka, Administrator and Lara Mlkeush, Administrator/Caregiver and a copy of the report left at the facility.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC809 (FAS) - (06/04)

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