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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004560
Report Date: 09/30/2024
Date Signed: 09/30/2024 10:39:34 AM

Document Has Been Signed on 09/30/2024 10:39 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:A & E CARE HOMEFACILITY NUMBER:
306004560
ADMINISTRATOR/
DIRECTOR:		HELEN C. HAFALIAFACILITY TYPE:
735
ADDRESS:13702 CORK STREETTELEPHONE:
(714) 867-6227
CITY:GARDEN GROVESTATE: CAZIP CODE:
92844
CAPACITY: 6CENSUS: 4DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Helen Hafalia, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Helen Hafalia, Administrator at 8AM.

The facility is a Level 2 single story building with four bedrooms and an approved fire clearance of six ambulatory. The facility currently has a census of four clients in care. Administrator stated she would like to change her capacity from six clients to four clients.

During today’s visit, LPA interviewed clients as they waited to be transported to Day Program. LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, and testing hot water temperature in two of two client bathrooms. The hot water temperature measured between 106.1 and 106.5 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on August 30,2024. The facility’s last fire drill was conducted on February 11, 2024 and Administrator planned to do the next one on October 1, 2024 . All of the client bedrooms have the required furnishings and were clean and organized.

LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. All knives and cleaning supplies were secured. LPA observed medication storage and reviewed the centrally stored medications. The First Aid Kit has all the required elements with a First Aid Manual. Per review medications are being given as prescribed.

LPA reviewed two of two staff training and fingerprint records and conducted a complete review of client records. Client P&I records were reviewed and were accurate. LPA interviewed alert clients regarding their quality of care and spoke to staff present regarding care provided.
(Continued on LIC 809-C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: A & E CARE HOME
FACILITY NUMBER: 306004560
VISIT DATE: 09/30/2024
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(Continued from LIC 809)

LPA spoke with Administrator regarding having Admissions Agreements that meet Title 22 requirements. Currently all clients have Regional Center Admissions Agreements that only comply with Title 17 regulations.. A Technical Violation will be given for the Admissions Agreements and quarterly drill. LPA confirmed that administrator has a current administrator certificate which expires on August 30, 2026.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Helen Hafalia, Administrator and a copy of the report, LIC 9102-TV and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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