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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004560
Report Date: 10/01/2021
Date Signed: 10/01/2021 10:58:34 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/01/2021 10:58 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:A & E CARE HOMEFACILITY NUMBER:
306004560
ADMINISTRATOR:HELEN C. HAFALIAFACILITY TYPE:
735
ADDRESS:13702 CORK STREETTELEPHONE:
(714) 867-6227
CITY:GARDEN GROVESTATE: CAZIP CODE:
92844
CAPACITY: 6CENSUS: 3DATE:
10/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Helen Hafalia, AdministratorTIME COMPLETED:
10:57 AM
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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted and granted entry into the facility by Administrator Helen Hafalia and explained the nature of the visit. This facility is licensed to provide services to 6 Ambulatory Clients. Facility is a level 2 home. Administrator (AD) AD Helen Hafalia has an Administrator Certificate with expiration date of 08/30/2022.

On or about 9:51am LPA Quiroz along with AD Helen Hafalia toured the inside and outside of facility. Two staff working at facility were observed to be wearing face masks upon arrival to facility. There are three clients in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz interacted with two of three clients in care. LPA Quiroz observed Client 1 (C1) in living room area, and Client 3 (C3) in his bedroom watching television. AD Hafalia indicated Client 2 (C2) is currently at Goodwill working. During today's visit, 2 of 3 clients present at facility appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected clients’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA Quiroz observed a check in station in the main entry of the facility. Facility is taking temperatures daily and documenting results. LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed seating area with table and chairs for client’s enjoyment in the front and back yard area. Facility has completed the LIC 808 Mitigation plan which was approved by Licensing Evaluator Jung Mi Han on 4/17/2021

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SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2021
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: A & E CARE HOME
FACILITY NUMBER: 306004560
VISIT DATE: 10/01/2021
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During today's inspection visit, LPA Quiroz reviewed three of three client records.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Administrator Hafalia during today's visit, and a copy of this report was provided to Administrator Hafalia at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
LIC809 (FAS) - (06/04)
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