195850262-9-9-2022-29-AS-ECAS-CJ4NPM-20220909103834

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850262
Report Date: 09/09/2022
Date Signed: 09/09/2022 10:39:13 AM

Document Has Been Signed on 09/09/2022 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	QUORA CARE		FACILITY NUMBER:	195850262
ADMINISTRATOR:	GOCHIN, RHODA		FACILITY TYPE:	740
ADDRESS:	22806 CALIFA STREET		TELEPHONE:	(747) 230-8689
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 0	DATE:	09/09/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Rhoda Gochin		TIME COMPLETED:	10:45 AM

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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility announced at 9:00 a.m. to conduct a pre-licensing inspection. The LPA met with Administrator Rhoda Gochin. This is a change of ownership application from Comfort Elderly Care (#195850162) to Quora Care (#195850262). The current capacity is for six (6) residents, the facility currently has zero (0) residents. The fire clearance was granted on 06/8/2022; in which bedroom #1 was cleared for ambulatory only, bedroom #2 and #4 were cleared for non-ambulatory clients and bedroom #3 was cleared for bedridden. Applicant successfully completed Component II on 06/28/2022. Component III was waived as the applicant currently operates two other Residential Care Facilities for the Elderly (RCFE)’s that are currently in good standing. Applicant has attended Component III in the past and is RCFE administrator certified.

At 9:00 a.m., the LPA toured the physical plant areas inside and outside with applicant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen knives are stored locked and inaccessible in the drawer next to the kitchen sink. The supply of perishable and nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. There is an adequate supply of emergency food.

BEDROOMS: There are five (5) bedrooms in the facility; the facility has four (4) bedrooms for resident use, and one (1) staff room. The staff room is kept locked. Room #3 has direct access to the outside. Lighting in the rooms appeared adequate. All resident rooms and one (1) staff room were set up with beds, nightstands, lamps, chests of drawers, chairs, TV’s and closet space.

Continued on LIC809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: QUORA CARE	FACILITY NUMBER: 195850262
	VISIT DATE: 09/09/2022

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BATHROOMS: There are two (2) full bathrooms both located in the main hallway designated for, residents, staff and guests. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. Between 9:09 a.m. and 9:11 a.m. the hot water temperature in bathrooms measured between 132.8 – 132.9 degrees Fahrenheit. The Administrator adjusted the water heater temperature at the time of the visit. LPA tested water temperature between 10:20 a.m. and 10:21 a.m. which registered between 131.9 and 132.4 degrees Fahrenheit. Administrator agreed to notify the department when water temperature has been regulated.

COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. The facility smoke alarm system is hard wired; the smoke detectors were operable at the time of the visit. There are two (2) fire extinguishers which were fully charged however had no proof of last serviced or purchase date. The Administrator was requested to have the extinguishers serviced or replaced and provide proof to CCL no later than 9/10/2022. There is a functioning telephone on the premises.

Emergency exiting plans/sketch are posted on the facility living room wall. Emergency telephone numbers are posted on the facility living room wall. Other required postings are posted in the dining room area and upon entry into the facility.

MEDICATIONS: Medications will be in a storage closet located in the facility dining room which is locked and inaccessible to residents in care. The first aid supplies were complete, including a first aid manual. Multiple first aid kits were observed throughout the facility.

FILES: Resident and staff records are stored in a storage closet located in the facility dining room.

LAUNDRY: The laundry area is located in the attached garage which is locked and inaccessible to residents in care.

Continued on LIC809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: QUORA CARE	FACILITY NUMBER: 195850262
	VISIT DATE: 09/09/2022

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EXTERIOR: The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs for resident use. There are no bodies of water noted on the premises. The back and sides of the house are separated from the front yard by gates at the north and south side passageways, both gates have self-latching mechanisms. There is a front yard gate with self-latching mechanism. There is no driveway gate. The facility has an attached garage used for laundry, storage and office space. There are no other structures on the property.

INFECTION CONTROL: The facility has a central entry point for symptom screening and sanitation station for staff, residents, and visitors. The facility has an adequate supply of PPE and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Facility is not compliance with Title 22 Regulations at this time. Applicant will be required to complete the following corrections and submit documentation to LPA Elsie Campos within 10 days:

- Documentation of water temperatures meeting Title 22 regulations.
- Documentation of Fire Extinguishers being serviced or replaced.

Upon receipt of the above items, physical plant will be in compliance with Title 22 regulations. This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new license number until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license. Exit interview conducted and report issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

LIC809 (FAS) - (06/04)

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