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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608877
Report Date: 01/07/2025
Date Signed: 01/07/2025 11:56:11 AM

Document Has Been Signed on 01/07/2025 11:56 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ALORA'S HOME CARE, INC.FACILITY NUMBER:
197608877
ADMINISTRATOR/
DIRECTOR:		EVANGELINE DE MATAFACILITY TYPE:
740
ADDRESS:22833 FRISCA DRIVETELEPHONE:
(661) 296-3244
CITY:VALENCIASTATE: CAZIP CODE:
91354
CAPACITY: 6CENSUS: 6DATE:
01/07/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:13 AM
MET WITH:Evangeline De Mata - Co AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced case management visit at this facility to issue a deficiency discovered during the course of the investigation on complaint control no.: 31-AS-20230727160520 wherein during Investigator Zertuche's interview, three (3) staff stated that staff #1 (S1) was sleeping on the sofa at the living room. LPA's record review during the initial visit on 07/28/23 also revealed that the facility did not report the incident occurred on 07/23/23 wherein Resident #1 (R1)'s arm was caught in own bed rail resulting hospitalization and fracture on R1's clavicle.

Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/07/2025 11:56 AM - It Cannot Be Edited


Created By: Jose Gary Tan On 01/07/2025 at 10:14 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALORA'S HOME CARE, INC.
FACILITY NUMBER: 197608877

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2025
Section Cited
CCR
87211(a)(1)(b)

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A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (b) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.
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The administrator agreed to retrain all staff on the provision of this regulation and submit proof of training to CCL on or before the POC date.
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This requirement is not met as evidenced by:

Based on record review, licensee did not report the incident occurred on 07/23/23 which cause R1 to have fracture, this poses a potential health and safety risk to the residents in care.
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Type B
01/13/2025
Section Cited
CCR87307(a)

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(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.
This requirement is not met as evidenced by:
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The administrator agreed to provide a statement the facility will no longer allow any staff to sleep in the common areas, including but not limited to living room sofa and submit to CCL on or before the POC date.
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Based on record review and interview licensee did not ensure that no staff sleep in the common area such as living room as S1 was reported to sleep on the living room sofa. This poses a potential health, safety and personal rights to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Troy Agard
LICENSING EVALUATOR NAME:Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


LIC809 (FAS) - (06/04)
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