306004367-3-12-2026-22-AS-JHAY-DS4PSY-20260312113508

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004367
Report Date: 03/12/2026
Date Signed: 03/12/2026 11:35:22 AM

Document Has Been Signed on 03/12/2026 11:35 AM - 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:	ARFEL CARE HOME 1		FACILITY NUMBER:	306004367
ADMINISTRATOR/ DIRECTOR:	ARIEL WATIN		FACILITY TYPE:	735
ADDRESS:	8881 PIERCE DRIVE		TELEPHONE:	(714) 827-7188
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 6		CENSUS: 2	DATE:	03/12/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:15 AM
MET WITH:	Ariel Watin		TIME VISIT/ INSPECTION COMPLETED:	11:55 PM

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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA was greeted, granted entry by staff and explained the reason for the visit.

Structure:

The facility is a single level structure and licensed for six non-ambulatory clients. As of today, there are six clients admitted to the facility. There’s a total of 6 bedrooms (all for clients), and two restroom areas available. There’s a living room space, a dining space, attached garage and backyard space. Bedrooms: 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. No chemicals observed in the bathroom. Kitchen: 4 of 4 burners are operational on the gas stove. Sharps are kept locked in a cabinet near the sink. Cleaning chemicals stored in the locked cabinet directly under the sink. Client medications are stored in the locked cabinets in the kitchen. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed in the kitchen.

Client & Staff Files: Client and staff files stored in locked file cabinets.
File Review: 3 of 6 client files were reviewed during the visit, and three staff files were reviewed.

Medications/First-Aid Kit: Client medications are stored in a locked medication cabinet in the kitchen. Two first aid kits were also observed in the kitchen area.

Medication Review: 3 of 6 client medications were reviewed during the visit. No discrepancies were noted. Medication is being administered as prescribed.

Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: ARFEL CARE HOME 1	FACILITY NUMBER: 306004367
	VISIT DATE: 03/12/2026

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Linens & Hygiene Supplies: Hygiene items are stored in client bedrooms, and additional hygiene items were observed in a locked closed in the main hallway.

Garage/Storage Room: The garage is clean and organized. There’s a laundry space with lock cabinets for cleaning chemicals, soaps, and detergents. There’s a filing cabinet for old paperwork and files. Two emergency disaster kits and emergency food supplies was observed in the garage area.

Backyard/Exterior: The backyard is clean and organized. Walkways are free of obstruction. A table equipped with a sunshade and chairs was observed.
Bodies of Water: None

Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational.
Fire Extinguisher: Fire extinguishers were observed mounted on a wall in the kitchen.

An emergency evacuation drill: Was conducted February 17, 2025. Evacuation drills are conducted quarterly.

Emergency Phone Numbers, House Rules, Exit Plan & Menu:

Several facility postings are posted and available for review on the main postings board near the entrance of the facility.

Additional Comments: Licensing fees are current. Facility contact information was confirmed during the visit. A mobile number was provided and will be added to the profile. P&I funds were reviewed for 3 of 6 clients. No discrepancies were noted. The emergency disaster plan was reviewed and looked good; however, Licensee/Administrator Watin was advised to find an additional relocation area outside of Buena Park.

No deficiencies are being cited during today’s visit.

An exit interview conducted, and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

LIC809 (FAS) - (06/04)

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