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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200608
Report Date: 12/27/2024
Date Signed: 12/27/2024 01:28:20 PM

Document Has Been Signed on 12/27/2024 01:28 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ST CATHERINE HOMEFACILITY NUMBER:
079200608
ADMINISTRATOR/
DIRECTOR:		JO, CHRISTOPHERFACILITY TYPE:
735
ADDRESS:1845 BADGER PASS WAYTELEPHONE:
(925) 577-4150
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 6DATE:
12/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Chris Jo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 12/27/24 at 11:30AM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. ADM has current administrator certificate# 7017635735 which expires on 11/15/2026.

At 12PM, LPA toured the facility including but not limited to the front entrance, screening station, hand washing stations, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizer were observed at the screening station. Cough/sneeze etiquette, social distancing signs were posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs maintained at a central location and easily accessible for staff. Comfortable temperature is maintained at 69 deg F. Facility has a mitigation plan in place and maintains records of routine screening for clients and staff. The infection control leader is the ADM. Fire extinguisher was observed fully charged and last inspected on 06/04/24. LPA reviewed 3 staff and 4 client files. LPA observed P&I monies matched record logs and kept separate from facility funds.

During visit, LPA observed the following deficiency:
  • Hot water temperature measured at 134.6

Continued on next page, LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ST CATHERINE HOME
FACILITY NUMBER: 079200608
VISIT DATE: 12/27/2024
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LPA obtained the following documents from ADM:
· LIC500- Personnel Report / Client Roster
· LIC308- Designation of Facility Responsibility
· LIC610D- Emergency/Disaster Plan including infection control plans
· Evidence of Surety Bond

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC 809D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/27/2024 01:28 PM - It Cannot Be Edited


Created By: Daisy Panlilio On 12/27/2024 at 01:20 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ST CATHERINE HOME
FACILITY NUMBER: 079200608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)


This requirement is not met as evidenced by: Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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By POC due date, Administrator agreed to submit to CCL a photo of corrected hot water temperature.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
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