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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001378
Report Date: 09/07/2022
Date Signed: 09/07/2022 01:15:45 PM

Document Has Been Signed on 09/07/2022 01:15 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. (JEFFERSON AVE)FACILITY NUMBER:
306001378
ADMINISTRATOR:ASUNCION GONZALESFACILITY TYPE:
735
ADDRESS:518 S. JEFFERSON AVENUETELEPHONE:
(714) 992-6774
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 6CENSUS: 6DATE:
09/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Michael San DirgoTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPA"s) Jenifer Tirre and Alvaro Ramirez 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. LPA's explained the reason for the visit.

During the visit LPA's toured the facility with Administrator Michael San Diego and Caregiver Lulu Taylor. Facility is a Level 3 Adult Residential Facility. Facility is a 4 bedroom,(3 client bedrooms 1 staff bedroom) and 2 bathrooms single story home. There are 6 Clients in care. LPA 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 including Emergency Disaster Plan, Infection Control Plan and Personal Rights. LPA's toured all Clients rooms, all rooms contained required furnishings. All restrooms observed contained soap, toilet paper, paper towels and hand sanitizer. Proper Hand washing signs posted. 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 at 105.6 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 a secured location for client medication and files. Facility has 30 days supply of medications for clients. LPA reviewed clients files during visit. Six out of six files were reviewed. Clients emergency contact information and Physicians reports are current. Facility has designated visitation areas.

No deficiencies noted during todays visit. An exit interview was conducted with Administrator Michael San Diego and a copy of report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2022
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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