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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004662
Report Date: 08/03/2022
Date Signed: 08/03/2022 12:13:27 PM

Document Has Been Signed on 08/03/2022 12:13 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
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:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Michael San DiegoTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted, granted entry into the facility by caregiver Sylvia Barlahan. LPA explained the reason for the visit. Administrator Michael San Diego was called and came down to facility.

During the visit LPA toured the facility with Administrator Michael San Diego. Facility is a Level 4D Adult Residential Facility. Facility is a 4 bedroom,(3 client bedrooms, 1 staff bedroom) and 2 bathrooms single story home. There are 5 Clients in care. At time of visit, 4 clients were away at Day program. LPA observed one client engaged in Day program activities outside in Designated visitor area with Day program staff. Client was well groomed and appeared neat in appearance. LPA observed proper covid signage at front entrance. Facility has a sink upon entry with soap and paper towels. Facility has a sign in, Temperature and sanitization station inside facility entrance. Facility has required Department postings. LPA observed Mitigation Plan and Emergency Disaster plan posted. LPA toured all Clients rooms, all rooms where within regulations. All restrooms observed had a working wash basin, contained soap, hand towels and toilet paper. Facility has hand washing signs posted. Facility has operating smoke detectors, carbon monoxide detector and audible alarms for each sliding door entrance/exit. Facility has 2 fire extinguishers which are fully charged. Facility water Temperature was measured at 104.3 Degrees Fahrenheit. Facility has supply of PPE. Facility has 2 refrigerators and 2 pantry's with ample food supply. LPA observed facility has emergency food and water supply. Facility has a secured location for sharps. Facility has a secured location for client medication and files. Facility has 30 days supply of medications for clients. LPA reviewed clients files during visit. 5 out of 5 clients files were reviewed. Clients emergency contact information and Physicians reports are current. LPA observed outside areas of facility and no items obstructed pathways. Facility has designated visitation areas.

No deficiencies noted during todays visit. An exit interview was conducted with Administrator Michael San Diego and a copy of report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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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