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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880624
Report Date: 03/09/2026
Date Signed: 03/09/2026 11:34:16 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/02/2026 and conducted by Evaluator Beena Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20260302140719
FACILITY NAME:GRACE HOME ATHENAFACILITY NUMBER:
331880624
ADMINISTRATOR:HAHN, JENNIFERFACILITY TYPE:
740
ADDRESS:35591 ATHENA CTTELEPHONE:
(714) 814-4287
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY:6CENSUS: 4DATE:
03/09/2026
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Facility Administrator Jennifer HahnTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Due to staff neglect, residents private area/buttocks is red.
Due to staff neglect, resident's tongue has crust on it.
INVESTIGATION FINDINGS:
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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
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 56-AS-20260302140719
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/09/2026
NARRATIVE
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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.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2