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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006599
Report Date: 10/28/2024
Date Signed: 10/28/2024 01:41:40 PM

Document Has Been Signed on 10/28/2024 01:41 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:AT HOME ELDER CAREFACILITY NUMBER:
306006599
ADMINISTRATOR/
DIRECTOR:		CATACUTAN, MARY JEANFACILITY TYPE:
740
ADDRESS:1919 E LOMITA AVETELEPHONE:
(949) 677-3394
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY: 6CENSUS: 6DATE:
10/28/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:55 AM
MET WITH:Mary Jean CatacutanTIME VISIT/
INSPECTION COMPLETED:
01:55 PM
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Licensing Program Analysts (LPA) Jerome Haley made an announced visit for the purpose of conducting a pre-licensing evaluation. LPA Haley was greeted and granted entry by applicant Mary Jean Catacutan.

Initial application: To operate a Residential Care Facility for the Elderly, with a capacity of 6 residents was submitted to the department for licensure.



Fire clearance: Orange County Fire Authority granted the Fire Clearance August 7, 2024

Structure:
The facility is a single level structure, with an attached garage. There’s a total of 8 bedrooms (5 resident & 3 staff), one living room space, one dining area, and four bathrooms (2 residents & 2 staff). Bedrooms (Residents): All bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. Grab bars are tightly secured in resident bathrooms. Hot water temperature measured in the range of 112.6 – 114.8 degrees Fahrenheit. Kitchen: 4 of 4 burners were operational on the gas stove. Sharps and hazardous cleaning chemicals are kept locked under the kitchen sink. Sharps are separated from the chemicals. Applicant was reminded to keep the items apart to prevent cross contamination. Food Service: LPA Haley observed a perishable and non-perishable food supply that meets resident requirements in the kitchen. An addition perishable and non-perishable food supply was observed in the garage. Office Area: N/A There is no designated office area. Laundry: There's a laundry area in the garage equipped with a washer and dryer. Toxins: All toxic chemicals and cleaning solutions are inaccessible to residents and locked under the sink. Additional chemicals are stored in the locked garage. Resident & Staff Files: Resident and staff files will be stored in a locked cabinet in the kitchen near the dining room.

Continued on LIC809C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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: AT HOME ELDER CARE
FACILITY NUMBER: 306006599
VISIT DATE: 10/28/2024
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Medications/First-Aid Kit: Resident medications are stored in a cabinet in the kitchen. Medications are stored right below the cabinet with staff and resident files. There’s a first aid kit with all the required elements stored in the medication cabinet.

Linens & Hygiene Supplies: Adequate supply of linen was stored in cabinets in the hallway.
Backyard/Exterior:
The back yard is clean and organized. The side exit gate is self-closing and self-latching. A shaded patio area with a table and chairs was observed. All walkways were clear and free of obstruction.
Bodies of Water: N/A. No bodies of water was observed.

Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational. Two plug-in carbon monoxide detectors (one near front door & one in the dining room) tested operational.
Fire Extinguisher: One fire extinguisher was observed mounted on the wall in the kitchen near the dining room. Another extinguisher was observed mounted on the wall in the hallway near the resident bedrooms.

Emergency Phone Numbers, House Rules, Exit Plan & Menu:
Posted & readily available for review on a postings board in between the kitchen and dining room was an emergency disaster plan, a list of emergency phone numbers, and house rules.

Component III: Presented to applicant Mary Jean Catacutan.

There are no corrections needed. The facility will be recommended for licensure.
An exit interview was conducted, and a copy of this report was provided to applicant Mary Jean Catacutan.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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