195850262-9-21-2023-29-AS-JOLN-CVW3EQ-20230921181132

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850262
Report Date: 09/21/2023
Date Signed: 09/21/2023 06:12:24 PM

Document Has Been Signed on 09/21/2023 06:12 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. #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: 4	DATE:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Paramgit Kaur, Licensee and Tsiana Mikia, Staff		TIME COMPLETED:	06:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jenny Olson arrived at the facility unannounced to conduct a required annual visit at 11:00 a.m. When LPA arrived, there were two staff and four residents present. LPA was greeted by Licensee around 11:40 am and informed them of the reason for the visit.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives are stored in a locked drawer in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

Common areas: Living and dining room furniture were observed to be in good condition. At 12:30 p.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. LPA observed required postings throughout the common space. The fire extinguisher was charged and but not serviced with a tag.

The backyard has a covered outdoor area equipped with furniture for client use. No bodies of water noted. The washer and dryer are in the garage. The garage is locked.

Restrooms: The two resident restrooms were clean and sanitary and in operating condition. The bathrooms were sufficiently stocked with soap and paper towels.

Bedrooms: There are four (4) resident rooms, which were furnished. A linen closet was located outside of the rooms, which stocked extra linens and towels.

Records: LPA reviewed resident and staff records around 11:15 a.m. LPA reviewed four (4) resident files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. No files were complete.

Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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: 09/21/2023

NARRATIVE

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LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. No files were complete.

MEDICATIONS: Medications review began at 4:00 p.m. The medications are centrally stored and locked in a closet in the dining room. Medications are labeled and checked for expiration dates. LPA advised Staff to ensure that all the necessary information is properly documented on the CSMAR.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s needs to submit an infection control plan to CCL ASAP.

LPA interviewed two (2) staff members and two (2) residents.

Staff and Licensee informed LPA that Labo Folayan was managing the facility, coming weekly to the facility as recently as 8-10 days ago to drop off groceries, medication and help out. Licensee stated Manager Labo has staff files in their office and was sending incident reports and death reports for them acting as manager.

On 07/06/2023 LPA Angel Ascencio met with Staff in person and Owner over the phone and delivered a complaint that stated: "The Department obtained a Decision and Order effective 01/19/2020 excluding Gbolabo "Labo" Folayan from being a licensee, owning beneficial ownership interest of 10 percent or more in a licensed facility, or being an administrator, officer, director, member, or manager of a licensee or entity controlling a licensee and further, from employment in, presence in, and from contact with clients of, of any facility licensed by the Department, for the remainder of their life."

Exit interview conducted, A copy of the report, citations, civil penalty, and appeal rights was printed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/21/2023 06:12 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.58(a)(2)

§1569.58(a)(2) The department may prohibit any person from being a licensee … an administrator … and ... prohibit any licensee from employing … or allowing contact with clients of a licensed facility … who has done … the following: (2) Engaged in conduct that is inimical to the health ... welfare, or safety ... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above, as an excluded individual has been seen in the facility and has been managing it, which poses an immediate health,safety and personal rights risk to residents in care.
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	The Administrator has agreed to do the following: Review Health and Safety Code 1569.58 and Regulation 87355 with all staff. Submit Statement of Understanding and sign-in sheet, acknowledging review, A repeat civil penalties was assessed in the amount of $1,000.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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