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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001378
Report Date: 09/27/2023
Date Signed: 09/27/2023 03:35:59 PM

Document Has Been Signed on 09/27/2023 03:35 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 ASC, 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:
09/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Michael San Diego - Assistance AdministratorTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility to conduct an unannounced Required 1 Year Inspection. At 2:00 pm, LPA was greeted and granted entry by House Manager Marialourd Taylor. Assistant Administrator Michael San Diego joined the inspection at approximately 2:15 pm.

Structure: The facility is a one-story home with three shared resident bedrooms, 2 bathrooms, living room, kitchen, dining room, staff bedroom, backyard and detached two car garage. The garage is only accessible via the large remote-operated garage door. The backyard has one exit gate. There is one shaded seating area in the backyard. House Manager showed LPA the facility’s garden, which Residents participate in maintaining. LPA did not observe any obstacles or hazards in the backyard.

Client Bedrooms: All resident bedrooms had the required furnishings. LPAs observed all resident beds had linens and blankets. LPA observed all windows were screened.

Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked beneath the kitchen sink.

Medications, First-Aid Kit & Book:
Medication will be stored in a locked cabinet in the living room. First aid kit is stored with the medication. The first aid kit has all the required elements.

Resident & Staff Files: Records will be kept locked in storage cabinet located in the living room. LPA reviewed the AD file, 3 staff files and 3 client files.

Fire Extinguisher: The fire extinguisher is fully charged.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2023
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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CATHERINE'S HOMES, INC. (JEFFERSON AVE)
FACILITY NUMBER: 306001378
VISIT DATE: 09/27/2023
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Activity Materials: The facility has coloring books, games, board games, and exercise equipment. Residents also have their own activity materials in their rooms

Bathrooms: All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 107.4 degrees Fahrenheit in the bathroom between the staff bedroom and laundry area. Hot water measured at 109.7 degrees Fahrenheit in the bathroom in the hallway.

Linens & Hygiene Supplies: A supply of extra linens and hygiene supplies are stored in cabinets in the bathrooms. Resident’s off-season clothing is also stored in the hallway closet

Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review

Food Service: There is a supply of 2-day perishable and 7-day of non-perishable food on hand.

Smoke Detectors: Dual Smoke and carbon monoxide detectors tested operational.

Appliances: Gas 4 burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational.

Based on the observations made during today's visit, no deficiency is being cited as per Title 22 Division 6 Chapter 2 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
LIC809 (FAS) - (06/04)
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