306004674-6-2-2023-22-AS-JTIE-CSERW7-20230602132241

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004674
Report Date: 06/02/2023
Date Signed: 06/02/2023 01:23:08 PM

Document Has Been Signed on 06/02/2023 01:23 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 & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CATHERINE'S RESIDENTIAL CARE HOME		FACILITY NUMBER:	306004674
ADMINISTRATOR:	MICHAEL SAN DIEGO		FACILITY TYPE:	735
ADDRESS:	700 W. ELM AVENUE		TELEPHONE:	(714) 525-8917
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92832
CAPACITY: 5		CENSUS: 5	DATE:	06/02/2023
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Administrator Michael San Diego		TIME COMPLETED:	02:00 PM

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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced Case Management visit and met with Administrator/Licensee Michael San Diego for the purpose of providing findings on an investigation regarding an allegation of neglect resulting in the sexual assault of Client 1 (C1).

A Special Incident Report (SIR) dated May 4, 2022 was received by Licensing Agency on May 5, 2022. The SIR reported that C1 and Staff 1 (S1) were outside together when S1 returned to the facility, leaving C1 outside alone for approximately 5 to 15 minutes. When S1 returned outside C1 was missing. S1 began looking for C1 and called the Administrator/Licensee. The Administrator/Licensee searched nearby neighborhoods and went to Fullerton Police Department and filed a police report. During this time the Licensee received a call from the facility that C1 was located and S1 was going to go pick them up. Licensee informed police and was instructed to go back to the facility to meet C1 and an officer would be on site for questioning since a missing persons case report was already filed.

During the questioning, C1 had disclosed to the Officer her boyfriend had kissed her on the cheek and grabbed her behind. C1 was asked where this alleged incident happened to which C1 stated a hotel. Upon further discussion with C1, Administrator/Licensee drove C1 to the area C1 was found where they were able to direct facility staff to a nearby motel. Upon review of security footage, C1 was observed to enter a bedroom with an unknown male where they remained for approximately two hours. C1 was then taken to Anaheim Regional Hospital for examination. Upon completion of the exam, the hospital staff informed S1 that there was no visible injuries to C1’s gentiles, however, evidence could be seen of sexual relations from the past along with suspicious bruising on C1’s leg.

Per facility body check form dated 5/5/2022 staff noticed bruising on C1’s inner left forearm and back left leg near knee. The following day additional bruising was noticed on C1’s upper left thigh.

CONTINUED ON 809C

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CATHERINE'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 306004674
	VISIT DATE: 06/02/2023

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Per physician report dated 6/3/2021 C1 has a diagnosis of Mild Intellectual Disability, Autism and Oppositional Defiant Disorder and is unable to leave the facility unassisted. Individual Program Plan received dated 08/27/2021 reports C1 had a known history of eloping and having challenging behaviors.

Based on the information gathered through interviews and documentation, the investigation confirmed that C1 had left the facility and was picked up by an unknown male who took C1 to a local motel and sexually abused C1.

As a result of investigation, a citation is being issued for Neglect/ lack of care and supervision of Client resulting in Client eloping from facility and being sexually assaulted.

The Licensee was informed that a civil penalty might be assessed based on Health and Safety Code 1548(f)(1).

The following deficiencies are cited today as per Title 22 of the California Code of Regulations, see LIC 809D.

An exit interview was conducted and a copy of this report along with copy of LIC 811 and LIC 809D and civil penalty assessed was given to Administrator/licensee Michael San Diego. A Copy of Appeal rights were provided at the time of the exit interview.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/02/2023 01:23 PM - It Cannot Be Edited

Created By: Jenifer Tirre On 06/02/2023 at 11:44 AM

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: 06/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/05/2023 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidence by the Licensee failed to provide adequate supervision to C1 resulting in C1 eloping. Per C1’s IPP, client is to be	1 2 3 4 5 6 7	Licensee shall ensure all staff have in service training of proper supervision procedures and send proof of training by due date.
	8 9 10 11 12 13 14	supervised by staff at all times and requires someone nearby to avoid injury/harm. This poses an immediate risk to the health and safety of the clients in care. IMMEDIATE CIVIL PENATLY ASSESSED	8 9 10 11 12 13 14
Type A 06/05/2023 Section Cited CCR80061(c)	1 2 3 4 5 6 7	Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours as required by Welfare and Institutions Code Section	1 2 3 4 5 6 7
	8 9 10 11 12 13 14	15630(b)(1). This requirement is not met as evidenced by the investigation interviews revealing Licensee failed to immediately report to licensing agency within 2 hours of clients in care.	8 9 10 11 12 13 14

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:

Luz Adams

LICENSING EVALUATOR NAME:

Jenifer Tirre

LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

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