Grace Home Athena

Type of visit: Required - 1 Year

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 *** 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.the state’s words, verbatim · CDSS document, Aug 19, 2026

Allegation investigated: Due to staff neglect, residents private area/buttocks is red. Due to staff neglect, resident's tongue has crust on it.

Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to initiate and deliver findings on the allegations listed above. LPA met with Facility Jennifer Hahn and explained the purpose of the visit. The investigation consisted of staff and resident’s interviews. LPA Singh conducted a health and safety walk through of the facility, while doing a walk through LPA Singh also interviewed residents in their rooms. There were three(3) residents at the facility and one(1) resident was out in the community. First allegation: Due to staff neglect, resident’s private area/buttocks is red. LPA Singh interviewed staff and residents and reviewed records pertinent to this investigation. Three (3) out of Three (3) Staff and Two(2) out of Three(3) residents interviewed stated that staff do/not neglect residents and assist residents and care residents in their care. Family of the resident#1 stated Staff at the facility always looked after Resident#1 while they were at the facility and happy with all the care staff has been providing to the resident#1 while in care and Staff and Family of resident#1 stated that R#1 did not have any redness on private area or buttocks while they were at the facility. Unsubstantiated Second Allegation: Due to staff neglect, resident's tongue has crust on it. LPA Singh interviewed staff, residents, gathered and reviewed records and conducted a walk through the facility. Three (3) out of Three (3) Staff and Two (2) out of Three (3) residents interviewed stated that staff do/not neglect residents and assist residents and care residents in their care and staff stated they always ensures residents are being looked after in their care. Also family of R#1 stated that resident#1 never had crust on her tongue while R#1 was at the facility and facility staff was always good and kind to R#1. Due to a lack of information, the above allegations are deemed UNSUBSTANTIATED at this time. Based on the evidence gathered during the investigation, the above allegation is found to be Unsubstantiated. Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report LIC 9099 was discussed and provided to Facility Administrator-Jennifer Hahn.the state’s words, verbatim · CDSS document, Mar 9, 2026 · control 56-AS-20260302140719

Type of visit: Required - 1 Year

On 08/11/2025, Licensing Program Analyst (LPA) Renese Howell-Small arrived unannounced to conduct the required annual visit to the facility. LPA met with staf, Bea Francisco and introduced self and stated the purpose of the visit. Administrator, Jennifer Hahn was contacted via telephone and informed of the purpose of the visit. LPA was informed that there are currently six (6) residents in care. The facility has six (6) bedrooms, four (4) bathrooms, kitchen, dining area, living room, office, laundry, attached garage and backyard. LPA completed a walk through of facility, review of records and medication audit. Physical Plant: The facility is operating as a Residential Care Facility for the Elderly, in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. LPA observed grab bars and non-slip mats in resident bathrooms. Water temperatures tested at 117 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarm, charged fire extinguishers and first aid kit. Postings: Posters such as; the personal rights, emergency disaster plan, CCLD complaint poster and ombudsman were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to residents. LPA observed potentially dangerous first aid liquids in an unlocked cabinet in the hallway. A deficiency was cited. There was a designated storage space for resident/staff files. Medications were observed to be locked and inaccessible to residents. There is no swimming pool, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for residents in care. Dishes, cups, and utensils were also stored properly. Yards/Outside: One shaded patio, one side gate with self-latching handle on the right side of the house that leads into the backyard. Record Review: LPA did not observe staff and administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Administrator will submit documents to LPA via email. LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. Three (3) Technical Violations, one (1) Technical Assistance were given and a deficiency was cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC09D, LIC9102 and Appeal Rights were discussed and copies were provided to staff, Bea Francisco.the state’s words, verbatim · CDSS document, Aug 11, 2025

The state marks this report as 8 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 07/27/2024 at 09:14 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. At the time of the visit there were two (2) staff present, and four (4) residents present. Licensee/Administrator Jennifer Hahn was contacted and informed of the visit. Licensee/Administrator Hahn arrived during the visit. LPA Brown explained the purpose of the visit to Licensee/Administrator Hahn. The facility is a six (6) bedroom, four (4) bathroom home with a kitchen/dining area, living room, activity room, laundry area and garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be bedridden. The facility has six (6) Hospice Waiver. The current census is four (4) residents. LPA Brown was accompanied by Staff #2 (S2) and Licensee/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 Brown observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit (F). LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps and storage space. LPA Brown observed sufficient lightning. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms. During the tour of the facility, LPA Brown observed Resident #2 (R2), has half bed rails. Licensee/Administrator Hahn reported to LPA Brown that R2 does not have written order from their physician indicating the need for half bed rail for mobility. Deficiency will be issued. ***Continuation in LIC809C *** LPA Brown observed sufficient furniture and lighting throughout the facility. Night lights were observed in the common hallway towards the residents' shared bathrooms. LPA Brown measured and observed the water temperatures in the bathroom to be at 110 degrees F. The facility is equipped with operating combined smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster, and the Emergency Disaster plan, Labor Laws were posted in a common area. There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked. First Aid KIt and First Aid Guide/Book were also observed at the facility Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility. Care & Supervision: The facility has an administrator present during the visit. However, during the staff interview, two (2) of two (2) staff interviewed reported no staff works at night, awake and on duty as required for facility with dementia residents. Deficiency will be issued. Record Review: LPA Brown reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. The files were complete with updated physician’s reports, admissions agreements, and preadmissions appraisals and needs and services plans. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA Brown observed that files reviewed were complete. During the medication audit, LPA Brown observed two (2) medications of Resident #2 (R2) were not given according to physician's directions as evidenced of discrepancy observed on the quantity of R2's two (2) medications. Deficiency will be issued. An exit interview was conducted where this report (LIC809), LIC809D, and Appeal Rights were discussed and provided to Licensee/Administrator Jennifer Hahn.the state’s words, verbatim · CDSS document, Jul 27, 2024