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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004662
Report Date: 08/28/2024
Date Signed: 08/28/2024 12:48:20 PM

Document Has Been Signed on 08/28/2024 12:48 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 RESIDENTIAL CARE HOMEFACILITY NUMBER:
306004662
ADMINISTRATOR/
DIRECTOR:		MICHAEL SAN DIEGOFACILITY TYPE:
735
ADDRESS:700 WEST AVENUETELEPHONE:
(714) 879-5139
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 6CENSUS: 5DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:00 AM
MET WITH:Administrator, Michael San DiegoTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 8/28/2024, Licensing Program Analyst's (LPA's) Jenifer Tirre and William Vanegas conducted an unannounced required visit using the CARE Inspection Tool. LPA's were greeted by caregiver and granted entry after stating the purpose of the visit. Administrator (AD) Michael San Diego was present to assist with the facility inspection on today's date.

The facility is a level four licensed for six (6) non-ambulatory clients. Currently, there are four clients present during today’s visit.

This is a single story home with detached garage facility. The facility has four bedrooms (three shared client rooms and one staff room), one staff office and two full bathrooms.

At around 7:20AM, LPA's conducted a tour of the physical plant accompanied by Administrator, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 109.4 degrees F. A comfortable temperature of 74 degrees F. was maintained in the facility.



LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, toxins and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Facility has two fire extinguishers which were mounted and fully charged. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance.

CONTINUED ON 809C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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 2
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 RESIDENTIAL CARE HOME
FACILITY NUMBER: 306004662
VISIT DATE: 08/28/2024
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During the visit, LPA's observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing station available in common areas and restrooms. LPA's observed the facility has a supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working land line phone was operational. The last fire drill was conducted on July 4, 2024. The facility had operational smoke and carbon monoxide detectors in bedrooms and common areas. The facility has current liability insurance on file effective 10/9/23- 10/9/24. The facility is current on Community Care Licensing annual dues.

A review of Five Clients (C1-C5) service files and three staff (S1-S3) personnel files revealed to be complete.

No deficiencies during this inspection visit.

An exit interview was conducted with Administrator, and a copy of the report was provided.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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