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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603239
Report Date: 10/01/2024
Date Signed: 10/01/2024 03:53:55 PM

Document Has Been Signed on 10/01/2024 03:53 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CASA KATERINEFACILITY NUMBER:
198603239
ADMINISTRATOR/
DIRECTOR:		TRAVIESO, YUSIMIFACILITY TYPE:
735
ADDRESS:6608 PINE AVENUETELEPHONE:
(562) 682-9667
CITY:BELLSTATE: CAZIP CODE:
90201
CAPACITY: 4CENSUS: 3DATE:
10/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Administrator Lourdes AlmeiidaTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Staff Paulina Nieto and explained the reason for the visit.
The purpose of the visit is to complete the required inspection.
LPA toured the facility along with Administrator Lourdes Almeiida today 10/01/2024 at 1:45 PM and the following was observed:
Facility contains 4 Client Bedrooms and 2 Client Bathrooms, dining room, living room, and TV room.
Annual Inspection includes the following Domains:
Infection Control, Physical Plant and Environmental Safety, Operational Requirements, Staffing, Personnel Records-Training, Client Rights- Information, Client records- Incident Reports, Food Service, Health related Services, Incidental Medical Services, and Disaster Preparedness.
Interview was conducted with 2 staff and 1 client. 1 client was at Day Program and attempts were made to interview the other client who was unable to respond to questioning because of diagnosis. 3 client files were reviewed and 6 staff files were reviewed. All staff were cleared and associated.
Medication was administered per physician's directions for all 3 clients.
Signage for hand washing and proper sanitizing were posted. Staff have been trained in hand washing.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained.
Facility had sufficient supply of 2 day perishable and 7 day non-perishables meeting regulations.
Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
There is an adequate number of direct care staff to support each resident's physical, social, emotional safety and health care needs as identified in his/her current appraisal.
Hot water temperature measured between 105-120 F. meeting Title 22 Regulations.
Facility has a sufficient supply of PPE.
No deficiencies. Exit interview conducted.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2024
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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