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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004662
Report Date: 03/19/2024
Date Signed: 03/19/2024 11:37:22 AM

Document Has Been Signed on 03/19/2024 11:37 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
ORANGE COUNTY RO, 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:
03/19/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator, Michael SanDiegoTIME COMPLETED:
11:50 AM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced Case Management visit to check on the Health and Safety and welfare of Clients in the facility. LPA met with Administrator Michael San Diego. LPA visited the facility to follow up on an Special Incident Report dated March 18, 2024 regarding client 1 (C1).

During Visit LPA toured facility with Administrator San Diego. LPA toured Kitchen, living rooms, client bedrooms and bathrooms. LPA observed facility to have working lights and lamps in each room. LPA observed bathrooms to have working water Basin and toilet. Facility has supply of hygienic supplies secured for each client such as soap, shampoo, conditioner, toothpaste, and mouthwash . LPA observed three shared client rooms, each room had beds neatly made with clear pathways. LPA observed C1's bedroom door to have chipped away paint. Administrator stated C1 had a behavior of picking at paint on walls. Staff stated to their knowledge C1 last picked door back in middle of February. LPA observed Toxins and sharps secured in cabinet.
Facility has two refrigerators and pantry with ample supply of perishable and non-perishable foods. LPA checked expiration dates and did not observe any expired items. Facility has emergency food and water supply. During visit facility had one staff on hand and one client waiting for their transportation to Day Program. LPA engaged in conversation with Client 2. Client 2 stated they like living at facility. C2 was observed as happy as evidence of smiling. Client was well groomed in appearance. LPA conducted three interviews, two with staff and one with client 2. No observations of neglect were observed.

LPA requested Individual Program plans for three clients, C1, C2, & C3. LPA requested copy of Police Report Case number.

An exit interview was conducted with Administrator and a copy of this report, along with the LIC 811, was provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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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