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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000159
Report Date: 03/22/2022
Date Signed: 03/22/2022 03:05:04 PM

Document Has Been Signed on 03/22/2022 03:05 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CATHERINE'S HOMES, INC.(534 WEST AVE)FACILITY NUMBER:
306000159
ADMINISTRATOR:CARLO M.P. GONZALESFACILITY TYPE:
735
ADDRESS:534 W WEST AVETELEPHONE:
(714) 525-2841
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 6CENSUS: 6DATE:
03/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Licensee, Cora Gonzales and Caregiver Warren QuizonTIME COMPLETED:
03:15 PM
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Licensing Program Analyst's (LPA's) Jenifer Tirre and Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required annual visit. LPA's were greeted, granted entry into the facility and temperature was checked by Staff and explained the reason for the visit.

During the visit LPA's toured the facility with Caregiver Warren Quizon and Licensee Cora Gonzales. Facility is a 4 bedroom,(3 client bedrooms 1 staff bedroom) and 2 bathrooms single story home. There are 6 Clients in care. LPA's observed proper covid signage at front entrance of facility as well as a sink upon entry with a sanitization station. Facility has required Department postings. LPA's toured all Clients rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper, paper towels and working water basin. Clients were observed relaxing in the Living room and bedrooms watching TV. Facility has 1 fire extinguisher which is fully charged. Facility water Temperature was measured between 111.0 and 114.6 Degrees Fahrenheit. Facility has supply of PPE. Facility has refrigerator and pantry with ample food supply. LPA's observed facility has emergency food and water supply. Facility has Mitigation Plan posted. Facility has a secured location for client medication and files. Facility has 30 days supply of medications for clients. LPA reviewed clients files during visit. Clients emergency contact information and Physicians reports are current. Facility has designated visitation areas.

An exit interview was conducted and copy of report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
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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