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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004674
Report Date: 09/06/2023
Date Signed: 09/06/2023 02:20:24 PM

Document Has Been Signed on 09/06/2023 02:20 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:
09/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Joan Baltazar
Michael San Diego		TIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Joan Baltazar. LPA discussed the purpose of the inspection and Administrator (AD) Michael San Diego was contacted by phone and arrived at 9:00 a.m.

During the inspection LPA and Staff Baltazar conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a one-story home with five client bedrooms, two bathrooms, and one staff bedroom. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed the back yard and front courtyard have a shaded sitting area. LPA observed one staff and one client present, as all other clients were away at day program. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 105.2 F degrees.

LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted at the entrance of the facility. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Facility does not have at least one internet access device dedicated to client use; a Deficiency was cited on today's date. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Stove burners, microwave, washer, and dryer were all inspected. Sharps were observed locked in a kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was observed to be unlocked and medication lock box located in the kitchen refrigerator containing medication was also unlocked; a Deficiency was cited on this date. LPA reviewed five client files and three staff files. Clients were not present to be interviewed. LPA interviewed one staff present. (Cont. LIC809-C)

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
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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Document Has Been Signed on 09/06/2023 02:20 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 09/06/2023 at 12:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CATHERINE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 306004674

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as medication cabinet and refrigerated medication lock box were observed to be unlocked, which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
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Facility staff locked both cabinet and lock box immediately. AD stated factility staff training will be conducted and proof of training will be provided to LPA via email by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/06/2023 02:20 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 09/06/2023 at 12:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CATHERINE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 306004674

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1537.1(a)
Regulations
(a) A licensee of a residential facility serving adults that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for client use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on AD admission, the licensee did not comply with the section cited above as facility does not have at least one internet access device dedicated to client use.
POC Due Date: 10/06/2023
Plan of Correction
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AD stated they would purchase a tablet for facility dedicated to client use. AD will provide LPA with purchase receipt and video proof of where in the facility the device will be kept by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 306004674
VISIT DATE: 09/06/2023
NARRATIVE
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Based on the observations made during today’s inspection, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
LIC809 (FAS) - (06/04)
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