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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002235
Report Date: 01/03/2024
Date Signed: 01/03/2024 01:51:06 PM

Document Has Been Signed on 01/03/2024 01:51 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. (ROOSEVELT)FACILITY NUMBER:
306002235
ADMINISTRATOR:CATHERINE GONZALESFACILITY TYPE:
735
ADDRESS:500 S. ROOSEVELT AVENUETELEPHONE:
(714) 738-5278
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 6CENSUS: 6DATE:
01/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Assistant Administrator - Michael San DiegoTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by DSP Jesse Magtibay. Assistant Administrator Michael San Diego joined the inspection ten minutes after LPA arrived.

The facility is a one-story home with three client bedrooms, two client bathrooms, kitchen, dining room, living room, staff bedroom, backyard and detached 2-car garage. LPA observed residents to be either away at day program or lounging in their bedroom. Facility appears clean and sanitary. All residents rooms had required elements, including bed, chair, closet space and ample lighting. Facility had extra linens for clients in the hallway closet. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured at 115.2 degrees Fahrenheit and 118 degrees Fahrenheit in the common bathrooms. LPA observed facility has emergency food and water supply. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in drawers in the kitchen. Cooking materials and chemicals are stored separately. Medication for each resident is kept locked in a cabinet in the dining room. The backyard has a shaded seating area. Exit gate is unlocked. LPA observed ramp and exit gate to be unobstructed. LPA reviewed three of the six client files, three personnel files, three clients' medication and the P&I. Files, Medication and P&I appear to be properly documented and stored. LPA interviewed two clients. Facility has board games, exercise equipment, electronics, a basketball hoop and more for client use. Emergency contacts, Menu and Calendar are posted and available for review.

No deficiencies noted during today's visit. An exit interview was conducted 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: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2024
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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