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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004674
Report Date: 08/23/2021
Date Signed: 08/23/2021 04:49:32 PM

Document Has Been Signed on 08/23/2021 04:49 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:
306004674
ADMINISTRATOR:MICHAEL SAN DIEGOFACILITY TYPE:
735
ADDRESS:700 W. ELM AVENUETELEPHONE:
(714) 525-8917
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 5CENSUS: 5DATE:
08/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Administrator, Michael San DiegoTIME COMPLETED:
04:55 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 and temperature was checked by Staff and explained the reason for the visit.

During the visit LPA toured the facility with Administrator Michael San Diego. Facility is a 6 bedroom,(5 client bedrooms 1 staff bedroom) and 2 bathrooms single story home. There are 5 Clients in care. LPA observed proper covid signage at front entrance of facility as well as a sink upon entry with a sanitization station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring October 05, 2021. LPA toured all Clients rooms, all rooms where within regulations. All restrooms observed contained soap, hand sanitizer, paper towels and toilet paper. Clients were observed relaxing in the Living room watching TV and relaxing in bedrooms. Facility has audible alarms for each sliding door entrance/exit. Facility has 2 fire extinguishers which are fully charged. Facility water Temperature was measured at 108.6 Degrees Fahrenheit. Facility has ample supply of PPE. Facility has 2 refrigerators and pantry's with ample food supply. LPA observed facility has emergency food and water supply. Facility has required Emergency Disaster Plan posted. 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. Clients emergency contact information and Physicians reports are current. 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: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2021
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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