374604410-4-21-2021-08-AS-AHAR-C2AU3D-20210421151322

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604410
Report Date: 04/21/2021
Date Signed: 04/21/2021 03:14:41 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	MARY CATHERINE'S HOME		FACILITY NUMBER:	374604410
ADMINISTRATOR:	BHAGAT, SUDARSHAN		FACILITY TYPE:	740
ADDRESS:	1540 DARLING DR		TELEPHONE:	(424) 344-8265
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY:	6	CENSUS: 2	DATE:	04/21/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:01 PM
MET WITH:	Sudsarshan Bhagat and Nisha Dogra		TIME COMPLETED:	02:43 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) Adam Hamer conducted an announced Pre-Licensing and Component III tele-visit via FaceTime due to COVID-19, to inspect facility for compliance with Title 22, Division 6, Chapter 8 of the California Code of Regulations and the Health & Safety Code. This is a change of ownership application, the facility has a capacity of six (6) and currently has two (2) residents in care. LPA identified himself at the beginning of the tele-visit and was joined on the video call by Applicant Sudarshan Bhagat and Nisha Dogra. LPA and Applicant toured the physical plant, inside and out, and LPA observed the following: Resident accommodations were in compliance, including furnishings, linens, and personal hygiene items; resident bathrooms were equipped with grab bars, non-skid mats, and water temperature measured at 105 degrees Fahrenheit in bathroom to be used by residents; the facility’s ambient room temperature was 71 degrees Fahrenheit at the time of the visit; there was a room with locked doors for medications and staff and resident records; food service, including dishes, utensils, food storage, and a seven day supply of non-perishables and a two day supply of perishables were present, and knives and sharp objects were locked in a cabinet under the sink; toxic substances were stored in a locked cabinet in the laundry room; first aid kits containing first aid manuals and proper supplies were stored in facility closets; activities, supplies and sufficient space in which to conduct activities were present; four (4) fire extinguishers were present, serviced in March 2021; smoke and carbon monoxide detectors were present and operable; required facility postings were present and visible in a common area of the facility. According to Applicant, there are no guns, weapons, or ammunition stored on the facility property. No swimming pool or other bodies of water were observed on the facility property during the visit. The administrators' certificates expire on June 30, 2021.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Adam Hamer	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021

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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MARY CATHERINE'S HOME	FACILITY NUMBER: 374604410
	VISIT DATE: 04/21/2021

NARRATIVE

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LPA conducted and completed the Component III with Applicant during the visit. LPA verified that Applicant’s understanding of Title 22 continuing requirements, including physical environment, reporting requirements, personnel and resident records, incidental medical care, health related services and activities.

All items reviewed during the visit are in compliance with Title 22, Division 6, Chapter 8 of the California Code of Regulations and the Health and Safety Code. Applicant was advised that the application is pending management final review and approval. An exit interview was conducted with Applicant and a copy of this report and Applicant Rights (LIC 9058) were provided to Applicant via electronic mail. LPA requested that Applicant send an email confirmation upon receipt of these documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Adam Hamer	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021

LIC809 (FAS) - (06/04)

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