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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004662
Report Date: 10/18/2021
Date Signed: 10/18/2021 11:16:12 AM

Document Has Been Signed on 10/18/2021 11:16 AM - 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 RESIDENTIAL CARE HOMEFACILITY NUMBER:
306004662
ADMINISTRATOR:MICHAEL SAN DIEGOFACILITY TYPE:
735
ADDRESS:700 WEST AVENUETELEPHONE:
(714) 879-5139
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 6CENSUS: 5DATE:
10/18/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Michael San DiegoTIME COMPLETED:
11:25 AM
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On this day Licensing Program Analysts (LPA's) Jenifer Tirre and Norman Woodridge conducted an unannounced Case Management visit to check on the Health and Safety and welfare of Clients in the facility. LPA's met with Administrator Michael San Diego. LPA's visited the facility to follow up on an Special Incident Report regarding a client (C1).

During Visit LPA's toured facility with Administrator San Diego LPA's toured Kitchen, living room, client bedrooms and bathrooms. LPA's observed facility to have working lights and lamps in each room. LPA's observed bathrooms to have working water Basin and toilet. Facility has supply of hygienic supplies such as soap, shampoo, conditioner, toothpaste, and mouthwash . Facility has fridge and pantry with ample supply of perishable and non-perishable foods. Facility has emergency food and water supplies. During visit facility had 2 staff on hand.

LPA's Observed 2 clients engaging in day program activities outside and 1 client doing virtual day program. LPA observed staff engaged with clients. LPA engaged in talking with clients and clients engaged in conversation. Clients were well groomed in appearance. No observations of neglect.


LPA requested pertinent documents regarding C1.


An exit interview was conducted with Administrator and a copy of this report, along with the LIC 811, was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2021
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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