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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002235
Report Date: 01/23/2025
Date Signed: 01/23/2025 12:28:38 PM

Document Has Been Signed on 01/23/2025 12:28 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. (ROOSEVELT)FACILITY NUMBER:
306002235
ADMINISTRATOR/
DIRECTOR:		CATHERINE GONZALESFACILITY TYPE:
735
ADDRESS:500 S. ROOSEVELT AVENUETELEPHONE:
(714) 738-5278
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 6CENSUS: 2DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Michael San DiegoTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Joseph Alejandre and Hanna Gough made an unannounced visit to conduct the required annual inspection. LPAs were greeted and granted entry by staff. LPAs met with Administrator (AD) Michael San Diego and explained the reason for the visit. The AD's administrator certificate expires on October 6, 2025. The facility is licensed as an Adult Residential Facility for 6 non-ambulatory clients. Facility is a single story house with 4 bedrooms, 2 bathrooms, kitchen, living room, dining room, and a detached 2 car garage. LPAs and AD toured the facility. LPAs observed bathroom 1 is clean and operational, hot water measured 120.2 degrees Fahrenheit. LPAs observed bathroom 1 is missing the window screen. LPAs observed bathroom 2 is clean and operational. Bathroom 2 does not have an outside window. LPAs toured the client bedrooms. All client rooms were clean and organized. All client rooms had the required bed linens and furnishings. LPAs and AD toured the kitchen. LPAs observed the kitchen is clean and organized. LPAs observed knives are kept locked in the kitchen drawer and cleaning supplies are locked under the kitchen sink. LPAs observed that 3 out of the 4 burners on the gas stove do not light unassisted. LPAs observed a 2 day perishable and 7 day non-perishable food supply on hand in the kitchen. LPAs observed that the fire extinguisher is in the kitchen and fully charged. Smoke detectors/carbon monoxide detectors tested operational. LPAs inspected the first aid kit and had all the required elements. The last fire drill was conducted on December 9, 2024. LPAs observed night lights in the hallway. LPAs observed the fireplace in the living room is inaccessible because there is a couch in front of the fireplace. The AD reported that the fireplace is never used. LPAs and AD toured the backyard and garage. The north exit gate is operational. There is a shaded patio with chairs and a bench for clients to sit outside. No bodies of water were observed in the backyard. The garage is kept locked and used for storage. No obstacles or hazards were observed in the backyard. LPAs reviewed 6 client files, no discrepancies observed. LPAs reviewed client medications. LPAs observed, Client 1(C1) was missing 5 out of 7 PRN medications, acetaminophen 325 mg, albuterol HFA 90 MCG inhaler, Ibuprofen 800 mg, loperamide 2mg, and milk of magnesia. No other discrepancies observed. LPAs reviewed 2 staff files.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 01/23/2025 12:28 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 01/23/2025 at 11:27 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. (ROOSEVELT)
FACILITY NUMBER: 306002235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above, LPAs observed that in bathroom 1 the window did not have a screen, which poses a potential health and safety risk to persons in care.
POC Due Date: 02/03/2025
Plan of Correction
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Licensee agrees to have a window screen installed in bathroom 1. Licensee to submit proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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4
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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2025 12:28 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 01/23/2025 at 11:33 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. (ROOSEVELT)
FACILITY NUMBER: 306002235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

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 1 out of 6 clients. Client 1 did not have 5 out of 7 PRNs which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
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Licensee agrees to have all of client 1s PRNs that are perscribed on hand and stored with the centralized medications by POC date.
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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2025 12:28 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 01/23/2025 at 11:51 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. (ROOSEVELT)
FACILITY NUMBER: 306002235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, LPAs observed that 3 out of the 4 burners on the gas stove did not light unassisted, which poses/posed a safety risk to persons in care.
POC Due Date: 02/03/2025
Plan of Correction
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Licensee agrees to repair or replace the stove so that all 4 burners light unassisted. Licensee will forward proof to LPA by POC due date.
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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


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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. (ROOSEVELT)
FACILITY NUMBER: 306002235
VISIT DATE: 01/23/2025
NARRATIVE
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Both staff members are background cleared and associated to the facility. Both staff members have the required training, including first aid training. LPAs and AD reviewed client P& I moneys. No discrepancies observed. The client ledger matches the moneys on hand. LPAs verified the facility has laptop for dedicated client use. Deficiencies are being cited per title 22 division 6 of the California Code of Regulation (CCR). An exit interview was conducted with the AD and a copy of the report along with appeal rights was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
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