<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004674
Report Date: 08/03/2022
Date Signed: 08/03/2022 02:30:50 PM

Document Has Been Signed on 08/03/2022 02:30 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:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:Administrator, Michael San DiegoTIME COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jenifer Tirre made 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. LPA explained the reason for the visit with Administrator Michael San Diego.

During the visit LPA toured the facility with Administrator Michael San Diego. Facility is a Level 4D facility. 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 Clients relaxing in living room, watching TV and relaxing in bedrooms. Clients appeared neatly dressed and well groomed. 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 toured all Clients rooms, all rooms where within department guidelines. All restrooms observed contained working wash basin, soap and toilet paper. Facility has hand washing signs. Facility has audible alarms for each sliding door entrance/exit. Facility has 2 fire extinguishers which are mounted and fully charged. Facility water Temperature was measured at 109.4 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 and mitigation 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. LPA reviewed 5 out of 5 files. LPA toured outside areas of facility. LPA observed secure location for hazardous toxins. 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)
Page: 1 of 1