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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609836
Report Date: 08/11/2021
Date Signed: 11/29/2021 03:16:22 PM

Document Has Been Signed on 11/29/2021 03:16 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ALORA'S VILLAFACILITY NUMBER:
197609836
ADMINISTRATOR:DE MATA, EVANGELINEFACILITY TYPE:
740
ADDRESS:25043 GREEN MILL AVETELEPHONE:
(818) 634-9860
CITY:SANTA CLARITASTATE: CAZIP CODE:
91321
CAPACITY: 6CENSUS: 6DATE:
08/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Chris Mendoza - AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Gary Tan met with co-administrator Chris Mendoza for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit.

A tour of the physical plant was conducted at 10:00 AM and the following was noted:

There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPAs were screened upon entry. All staff were observed to be wearing mask upon entrance and during visit.

The facility had submitted and approved Mitigation plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

The facility has six (6) bedrooms and three (3) bathrooms currently occupying six (6) residents. There is an additional dwelling unit located on the way to the garage with their own bathroom for staff use. The facility is fire cleared for six (6) non-ambulatory residents, one (1) of which may be bedridden. Hospice waiver for six (6) residents.

(continued on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2021
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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ALORA'S VILLA
FACILITY NUMBER: 197609836
VISIT DATE: 08/11/2021
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(continued on LIC 809-C)

Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 76°F. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide installed at the facility. Fire extinguishers are located in the kitchen laundry room and observed to be full and last inspected on 10/22/20. The facility is equipped with fire sprinkler.
The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility.
The garage is currently being used as frozen food, tools, old equipment and other supplies storage. Laundry room is located in a room on the way to the garage. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the laundry area. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.



Staff Rooms: Staff room was observed to be locked, located adjacent to the laundry room going to the garage. No medications are observed in the staff room.

The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was measured at a range of 135.6°F to 139.2°F. Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet.

Medications: LPA observed medication cabinet to be locked and inaccessible to residents, located near the kitchen. There is a complete first aid kit located inside the medication cabinet.

Citation issued. Appeal right discussed and given. Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/29/2021 03:16 PM - It Cannot Be Edited


Created By: Jose Gary Tan On 08/11/2021 at 12:04 PM
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 VILLA
FACILITY NUMBER: 197609836

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation during physical plant tour, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2021
Plan of Correction
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Admnistrator immediately adjusted the water temperature and last measured at 117.6°F. Cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Naira Margaryan
LICENSING EVALUATOR NAME:Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2021


LIC809 (FAS) - (06/04)
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