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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004674
Report Date: 05/10/2022
Date Signed: 05/10/2022 11:20:05 AM

Document Has Been Signed on 05/10/2022 11:20 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:
306004674
ADMINISTRATOR:MICHAEL SAN DIEGOFACILITY TYPE:
735
ADDRESS:700 W. ELM AVENUETELEPHONE:
(714) 525-8917
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 5CENSUS: 5DATE:
05/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Michael San DiegoTIME COMPLETED:
11:35 AM
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This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Ruth Martinez. LPA arrived at facility was greeted and granted entry by caregiver. Michael San Diego, Administrator arrived shortly after and met with LPA. LPA explained the nature of the visit to Administrator.

LPA Martinez is conducting this visit in response to an incident report of possible personal rights violation for C1. Incident was self reported on May 05, 2022 regarding C1’s incidents on May 04, 2022. This visit is being conducted for the purpose to review and collect facility records.

During today’s visit, LPA took a tour of the facility physical plant, completed a review of clients records, completed a review of staff records and obtained copies of pertinent documents.

This report was reviewed with Administrator and a copy of the LIC809 and LIC811 was provided and left at the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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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