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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004674
Report Date: 08/28/2024
Date Signed: 08/28/2024 04:35:04 PM

Document Has Been Signed on 08/28/2024 04:35 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:
306004674
ADMINISTRATOR/
DIRECTOR:		MICHAEL SAN DIEGOFACILITY TYPE:
735
ADDRESS:700 W. ELM AVENUETELEPHONE:
(714) 525-8917
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 5CENSUS: 5DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Administrator, Michael San DiegoTIME VISIT/
INSPECTION COMPLETED:
04:45 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 staff and granted entry after stating the purpose of the visit. Administrator (AD) was present to assist with the facility inspection on today's date.

The facility is licensed for five (5) non-ambulatory clients. Currently, there are four (4) clients present during today’s visit.

This is a level four single story home with a detached car garage facility. The facility has six bedrooms (five clients and one staff), two full bathrooms.

At around 2:10PM, 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 106.1 degrees F. A comfortable temperature of 75 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 and sharps objects were stored and not accessible to residents. 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: 306004674
VISIT DATE: 08/28/2024
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During the visit LPA observed the facility has a supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. Facility has emergency food and water supply.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on August 12, 2024. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 10/9/2023 - 10/9/2024. The facility is current on Community Care Licensing annual dues.

A review of five clients (C1-R5) service files and two staff (S1-S2) 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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