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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000159
Report Date: 03/04/2025
Date Signed: 03/04/2025 12:04:18 PM

Document Has Been Signed on 03/04/2025 12:04 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/
DIRECTOR:		CARLO M.P. GONZALESFACILITY TYPE:
735
ADDRESS:534 W WEST AVETELEPHONE:
(714) 525-2841
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 6CENSUS: 6DATE:
03/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:03 AM
MET WITH:Michael San Diego- Administrator
TIME VISIT/
INSPECTION COMPLETED:
12:17 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Nancy Guillen and Hanna Gough conducted an unannounced visit for the purpose of completing an annual required inspection. LPAs arrived at the facility and were greeted and granted entry by caregiver Rogie Mario Salazar and LPA explained the nature of the visit. Administrator, Michael San Diego, was notified via telephone and arrived shortly to assist with the visit.

Six clients reside at this facility and were away at their Day Programs. LPAs began the tour of the inside and outside of the facility. LPAs observed required department postings posted on the wall of facility. Facility license was also posted at the facility, however facility was does not stay within the capacity limitations; a deficiency was cited on today’s date. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional emergency food and water storage in the storage room. The facility is maintained at a comfortable temperature. LPAs observed that medication is centrally stored in a locked storage closet located by the facility entrance. LPAs reviewed medication and observed medication was labeled and stored inaccessible to clients in care. LPAs inspected the bathroom and LPAs measured the hot water temperature which measured 110.4 and 113.9 degrees Fahrenheit. All bathrooms observed to have a supply of soap, toilet paper and towels. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPAs observed that toxic chemicals, cleaning solutions and disinfectants are stored locked under the kitchen sink. The facility has an available clean supply of linens. LPAs inspected client’s bedrooms which have sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Smoke detectors and carbon monoxide were tested and found to be operational. LPAs toured the outside of the facility and observed outdoor passageways are free of obstructions. LPAs observed there is shaded seating areas for client’s enjoyment. LPAs observed a fire extinguisher with service date of June 22, 2024, by the kitchen. The last disaster drill conducted was a fire drill done on February 23,2025 and is conducted every three months.

Continued on LIC 809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Nancy Guillen
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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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Document Has Been Signed on 03/04/2025 12:04 PM - It Cannot Be Edited


Created By: Nancy Guillen On 03/04/2025 at 11:17 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CATHERINE'S HOMES, INC.(534 WEST AVE)
FACILITY NUMBER: 306000159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(a)
Limitations on Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three out of five client's physician reports reviewed, which poses an immediate safety rights risk to persons in care due to operating outside facility license capacity.
POC Due Date: 03/05/2025
Plan of Correction
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Administrator to send written plan of how POC is to be cleared to LPA by POC date. Administrator stated new physician reports will be provided to LPA via email by March 18, 2025.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Nancy Guillen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


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: 03/04/2025
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 LPAs began review of records. LPAs reviewed six clients’ records. All the required documentation was present and current in client’s files reviewed. The facility P&I records were reviewed and no discrepancies were observed and attached receipts were kept for record keeping. LPAs reviewed four employee records. All employees present have a criminal record clearance and are associated to the facility. LPAs observed records reviewed have a current First Aid certificate. Administrator was notified of pending annual fees.

Based on the observations made during today’s inspection, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Nancy Guillen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
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