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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004560
Report Date: 10/04/2022
Date Signed: 10/04/2022 04:32:37 PM

Document Has Been Signed on 10/04/2022 04:32 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: 4DATE:
10/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:09 PM
MET WITH:Helen Hafalia, Licensee/Administrator TIME COMPLETED:
04:40 PM
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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced Case Management- Incident inspection visit. LPA Quiroz was granted entry by Staff 2 (S2) and met with Licensee/Administrator (L/AD) Helen Hafalia and discussed purpose of the inspection visit.
On 10/03/2022, Orange County Regional Office CCL received a special incident reporting indicating that on 9/27/22 Client #1 (C1) on or about 5:00pm, left facility unassisted and missed his evening and morning medications of 9/28/22 and returned back to facility on 9/28/22 on or about 8pm. It was also reported that on 9/29/2022, (C1) left facility on or about 4:00am, and Licensee/Administrator Helen Hafalia and S2 went to go look for (C1) and located (C1) at 7 Eleven store approximately 2.6 miles away from the facility. On both occasions, (L/AD) informed C1's Responsible Party (RP) and Orange County Regional Center (OCRC).
(L/AD) Hafalia indicated OCRC and C1s (RP) and (L/AD) Hafalia will be meeting on 10/5/22 at 3:00pm to discuss C1s recent elopement behaviors both within the same week. (L/AD) Hafalia indicated OCRC Service Coordinator indicated that a request for additional staff has been submitted and that OCRC is seeking extra funding to provide additional staff supervision for C1 due to increase elopement behavior while residing at this facility. C1 was admitted to facility on 8/25/2022.
C1 has a history of running/wandering away occurring at least once per month, but not every week. Individual Program Plan (IPP) dated 7/5/2022 page 8 of 11 indicates C1 "has a history of running away and being a recluse and that he has become better with this but still happens on occasion when he is extremely upset. He will leave the house and not return for a few days at a time."
On today's date, LPA Quiroz observed C1 arriving from work on or about 3:10pm. LPA Quiroz introduced self to C1, and interviewed C1 during today's visit . C1 appeared to look in good spirits and was dressed weather appropriate.

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SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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: 10/04/2022
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CONTINUED...

During today's inspection, LPA conducted a health and safety check and found 4 of 4 clients to be at the facility and observed no health and safety issues.
LPA Quiroz interviewed (L/AD) Helen Hafalia and S2 who confirmed the details previously reported on incident report dated 10/1/2022.
The Physician report dated 9/12/2022 indicated C1 may not leave facility unassisted. L/AD Hafalia indicated "This is something that I'm going to discuss with C1s responsible party and OCRC Service Coordinator because they want C1 to go to the gym, keep himself active and be independent as much as possible. I think the request to have more additional staff to supervise C1 is a great thing. OCRC Service Coordinator has already submitted that additional staff request." During today's visit, LPA Quiroz called OCRC Service Coordinator assiged to C1 requesting a call back. (L/AD) Hafalia agreed to call LPA Quiroz with follow up after meeting with C1s responsible party and OCRC Service Coordinator on 10/5/2022.
The facility maintains a checkout log for clients. Facility staff check to make sure all clients are present every morning at 4:30am and at 9:00 pm each night and if a client is not present, facility staff will inform (L/AD) Hafalia and call the family; If clients are not with the family, facility staff will call the police and notify all pertinent parties involved in client's well being. LPA requested copies of the following for C1: Physician report, sign out log, progress notes, and IPP which were received during today's visit.

At this time, no deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with (L/AD) Hafalia. This report along with the LIC 811s were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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