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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000159
Report Date: 03/05/2024
Date Signed: 03/05/2024 05:09:29 PM

Document Has Been Signed on 03/05/2024 05:09 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
ORANGE COUNTY RO, 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:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator's Michael San Diego & Warren QuizonTIME COMPLETED:
05:30 PM
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On 3/05/2024, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by Administrator Warren Quizon and granted entry after stating the purpose of the visit. Administrator Quizon contacted Licensee/ Administrator Michael Sandiego who arrived to facility shortly after.

The facility is licensed for six (6) non-ambulatory. There were two residents present during today’s visit.

This is a single story with attached garage facility. The facility has five bedrooms ( three shared client rooms & two staff rooms) and two full bathrooms.

At around 1:57PM, LPA conducted a tour of the physical plant accompanied by Administrator Warren Quizon, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured between 105.8 to 107.7 degrees F. A comfortable temperature of 68 degrees F. was maintained in the facility.



LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored. Sharps and toxins are not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was fully charged. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance.

CONTINUED ON 809C
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CATHERINE'S HOMES, INC.(534 WEST AVE)
FACILITY NUMBER: 306000159
VISIT DATE: 03/05/2024
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and clients, and sanitizing stations near entrance and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 1/5/2024. The facility had operational smoke and carbon monoxide detectors in bedrooms and common areas. The facility has current liability insurance on file effective 3/18/23- 3/18/2024. The facility is current on Community Care Licensing annual dues.

A review of two clients (C1-C2) service files and three staff (S1-S3) personnel files revealed to be complete. The facility has the current administrator's certification on file for Warren Quizon # 6067460735 - Expiration 9/6/2025.

No deficiencies during this inspection visit.

An exit interview was conducted with Administrator, and a copy of the report was provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
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