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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610369
Report Date: 05/09/2024
Date Signed: 05/09/2024 01:28:58 PM

Document Has Been Signed on 05/09/2024 01:28 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ALORA'S SENIOR HOMEFACILITY NUMBER:
197610369
ADMINISTRATOR/
DIRECTOR:		DE MATA, EVANGELINEFACILITY TYPE:
740
ADDRESS:23217 CUERVO DRIVETELEPHONE:
(661) 388-1524
CITY:VALENCIASTATE: CAZIP CODE:
91354
CAPACITY: 6CENSUS: 4DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Evangeline De MataTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted unannounced Annual Required inspection. LPA entered the facility and observed staff in the common area. LPA informed staff the purpose of the visit, who contacted the Administrator. LPA spoke to Administrator over the phone, who arrived shortly after. LPA checked personnel summary report to verify fingerprint or association clearance, and it was observed all staff is cleared. The facility is licensed to serve for (6) elderly residents, age (60) and over. Currently the facility’s census is (4), with (1) resident on hospice. LPA observed facility license and sketch, emergency disaster plan, grievance/complaint procedures, personal rights, rights of resident council, resident bill of rights, and emergency disaster plan visibly posted the wall; including COVID signs.

LPA toured the physical plant inside and outside with staff. LPA inspected resident bedrooms, bathrooms, and common areas, to ensure there were no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility has (6) bedrooms, with (1) room for staff and (2) bathrooms. Inside temperature was comfortable, and LPA observed all areas to be clean and appropriately furnished for resident’s comfort and safety. LPA reviewed the food service and storage area, and it was observed to have a sufficient supply of perishable and nonperishable. The facility stores extra refrigerator in the garage, with fresh fruit, vegetables, and frozen meat. Storage areas for toxins, knives, and medication were locked and secured. Hot water temperature measured at 109.4 degrees Fahrenheit. Bathrooms are provided with soap, towels, non-skid mat, and grab bars were located by shower and toilet. Smoke and carbon monoxide detectors are hard-wired and were operating correctly. Fire extinguishers are fully charged. First aid kit had sufficient supplies including tweezers, scissors, thermometer and first aid manual. The backyard had clear passageways and free from obstruction, with gates easily accessible. Patio furniture area had comfortable table and chairs for residents.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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Document Has Been Signed on 05/09/2024 01:28 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 05/09/2024 at 12:27 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 SENIOR HOME
FACILITY NUMBER: 197610369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and during today's visit, the licensee did not comply with the section cited above in had incomplete personnel records for staff # 1(S1). This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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Administrator will submit documents requested by LPA by the POC date.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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Administrator will submit documents requested by LPA by the POC date.
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:Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/09/2024 01:28 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 05/09/2024 at 12:27 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 SENIOR HOME
FACILITY NUMBER: 197610369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.626(a)(2)
Other Provisions
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (2) Eight hours of in-service training per year on the subject of serving residents with dementia. This training shall be developed in consultation with individuals or organizations with specific expertise in dementia care or by an outside source with expertise in dementia care. In formulating and providing this training, reference may be made to written materials and literature on dementia and the care and treatment of persons with dementia. This training requirement may be satisfied in one day or over a period of time. This training requirement may be provided at the facility or offsite and may include a combination of observation and practical application.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review), the licensee did not comply with the section cited above in [2] out of [2] missing training records for staff and had incomplete personnel records. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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Administrator will submit the required documents requested to LPA by POC date.

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:Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 SENIOR HOME
FACILITY NUMBER: 197610369
VISIT DATE: 05/09/2024
NARRATIVE
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LPA checked centrally stored records, and medication records, and observed files had incomplete records and missing information. Resident and staff files reviewed, LPA observed missing training records, incomplete records and documents. This is a potential health and safety risk to residents in care.

Citation and technical violations issued; exit interview copy of report, and appeal rights provided.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4