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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004560
Report Date: 08/10/2022
Date Signed: 08/10/2022 01:56:32 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/10/2022 01:56 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
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:
08/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Perlita Cadiz, House ManagerTIME COMPLETED:
02:11 PM
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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, COVID-19 screened and granted entry into the facility by Perlita Cadiz, House Manager (HM) and explained the nature of the visit. This facility is licensed to provide services to 6 Ambulatory Clients. Facility is a level 2 home. LPA Quiroz called and spoke to Licensee/Administrator (L/AD) L/AD Helen Hafalia during today's visit who indicated not being able to attend today's annual inspection visit due to personal appointment. L/AD Helen Hafalia has an Administrator Certificate with expiration date of 08/30/2022.

On or about 12:37 pm LPA Quiroz along with (HM) Perlita Cadiz toured the inside and outside of facility. Staff working at facility was observed to be wearing face mask 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. Client 3 is Vietnamese speaking only. LPA Quiroz observed three of three clients in their bedroom watching television comfortably. Client's bedrooms temperature recorded to be between 77-79 degrees Fahrenheit.

During today's visit, 3 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 in kitchen area and main hallway closet readily available for clients in care. 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.

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SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2022
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: 08/10/2022
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During today's inspection visit, LPA Quiroz reviewed three of three client records and 2 of 2 staff 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 (HM) Perlita Cadiz during today's visit, and a copy of this report and LIC 811-Confidential Names were provided at exit.

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

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC809 (FAS) - (06/04)
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