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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001378
Report Date: 02/09/2024
Date Signed: 02/09/2024 03:22:51 PM

Document Has Been Signed on 02/09/2024 03:22 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:
02/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Michael San Diego - Assistant AdministratorTIME COMPLETED:
03:40 PM
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On February 9, 2024, Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility at 2:00pm to conduct a Case Management Inspection regarding an Unusual Incident Report received by Community Care Licensing (CCL) on February 8, 2024. LPA was greeted and granted entry by DSP, Eloida Quimbao. LPA stated the reason for the inspection. Assistant Administrator Michael San Diego joined the inspection at approximately 2:15pm.

LPA conducted a Health and Safety check. Clients were observed to be watching television and eating snacks in the living room or spending time in their own room. One client was noted to be at Day Program. LPA did not observe any areas of concern during the Health and Safety Check.

LPA requested copies of documents from the file of the client associated with the SIR. These documents include: Face Sheet, Pre-Placement Information, Admission Agreement, two Physician's Reports, IPP, Behaviorist Report, and the Facility's quarterly report on the overall well being of the client.

An exit interview was conducted with Assistant Administrator Michael San Diego and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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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