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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005565
Report Date: 03/10/2025
Date Signed: 03/10/2025 03:35:53 PM

Document Has Been Signed on 03/10/2025 03:35 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:AK AND DAVID SENIOR CAREFACILITY NUMBER:
306005565
ADMINISTRATOR/
DIRECTOR:		CATACUTAN, MARY JEANFACILITY TYPE:
740
ADDRESS:24302 BARK STTELEPHONE:
(949) 677-3394
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 5DATE:
03/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Administrator Mary Jean CatacutanTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by care giving staff after explaining the purpose for the visit. Administrator (AD) Mary Jean Catacutan was notified via telephone and later arrived to assist with the inspection. LPA observed that Administrator Mary Jean Catacutan has a valid Administrator certificate which expires on August 2, 2025.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents and has a hospice waiver for three. The facility is a two story home with five resident bedrooms, all of which are located on the first floor, two staff bedrooms, both are which are located on the second floor, three resident bathrooms, two of which are shared, a living room, a dining room, a kitchen, and an attached two car garage. LPA accompanied by the AD conducted a tour of the interior portion of the facility. On today's visit, LPA observed five residents in care, one of which is on hospice, and two care giving staff present. LPA observed residents relaxing in the living room and in their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall in the dining room. LPA inspected the five resident bedrooms, and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. All resident beds had clean linens and blankets. LPA observed additional linens to be stored in a hallway closet. LPA tested the signal system in each of the resident bedrooms which tested operational. LPA inspected the three resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 105.8 and 110.6 degrees Fahrenheit. LPA observed the second floor to be for staff use only and off limits to residents in care. LPA observed staff bedrooms to be clear of hazards.

LPA observed the kitchen has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. CONTINUED ON LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: AK AND DAVID SENIOR CARE
FACILITY NUMBER: 306005565
VISIT DATE: 03/10/2025
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The four burner gas stove lights unassisted. LPA observed knives and sharps to be stored in a locked kitchen cabinet. LPA observed chemicals and toxins to be stored in a locked kitchen cabinet under the sink.
A fire extinguishers is located in the entryway of the facility and it was observed to be charged and serviced as of February 6, 2025. LPA tested the individual smoke detectors which tested operational. LPA tested the individual carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on January 18, 2025. The centrally stored medication is kept in a locked cabinet in the kitchen. A First Aid kit was observed be stored in the locked kitchen cabinet and it was observed to have all the required components. LPA observed a fire place in the living room and it was observed to not be in operation at the time of visit. The door leading to the attached two car garage is kept locked and inaccessible to residents. The garage is used for storage and laundry. LPA observed chemicals and toxins to be stored in the locked two car garage. LPA observed additional linens and blankets to be stored in the garage. LPA observed the facility has a three day emergency food and water supply to be stored in the garage.

LPA and the AD conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gate on the north side of the facility is self-latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed all five resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed all five residents’ medication and medication records. LPA reviewed four staff files. All staff are background cleared and associated to the facility.

Based on today's observations, no deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Mary Jean Catacutan and a copy of the report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
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