<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850262
Report Date: 11/16/2023
Date Signed: 11/16/2023 04:45:45 PM


Document Has Been Signed on 11/16/2023 04:45 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:QUORA CAREFACILITY NUMBER:
195850262
ADMINISTRATOR:GOCHIN, RHODAFACILITY TYPE:
740
ADDRESS:22806 CALIFA STREETTELEPHONE:
(747) 230-8689
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 3DATE:
11/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Tsiana Mikia, StaffTIME COMPLETED:
04:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Emily Peraldi conducted a Case Management - Deficiencies visit in conjunction with a complaint visit. The purpose of the visit is to issue a citation for a deficiency observed during the complaint investigation. At 10:37 a.m., the LPA met with staff. At 4:16 p.m., the LPA spoke with the applicant Pogos Tofalyan. The applicant was not available to meet the LPA and authorized staff, Tsiana Mikia to sign the report.

During record review at 10:50 a.m., the following was noted: All residents did not have resident files nor completed files available at the facility.

During the physical plant tour at 11:06 a.m., the LPA observed the following: The fireplace was not adequately screened. Resident restrooms did not have non-skid mats or strips shall inside bathtubs and showers. Medication observed outside accessible to residents in care.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8 and California Health and Safety Code the following deficiencies were observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
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 3


Document Has Been Signed on 11/16/2023 04:45 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: QUORA CARE
FACILITY NUMBER: 195850262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/24/2023
Section Cited
CCR
87307(d)(7)

1
2
3
4
5
6
7
87307(d)(7)Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities:(7) Fireplaces and open-faced heaters shall be adequately screened. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Licensee agreed to adequately screen the fireplace and send proof to CCL by due date.
8
9
10
11
12
13
14
Based on observations, the licensee did not comply with the section cited above as the fireplace was not adequately screened which poses a potential health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
Type B
11/30/2023
Section Cited
CCR87506(a)

1
2
3
4
5
6
7
87506(a) Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility…readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Licensee agreed to complete all resident files by due date.
8
9
10
11
12
13
14
Based on record review, the Licensee did not comply with the section cited above as there were no files or incomplete files present at the facility for all three (3) residents which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 11/16/2023 04:45 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: QUORA CARE
FACILITY NUMBER: 195850262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2023
Section Cited
CCR
87705(f)(2)

1
2
3
4
5
6
7
87705(f)(2)Care of Persons with Dementia (f)The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication...This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to the following:
1. To immediately lock any accessible medication. Plan of correction met at the time of the visit.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above as there was accessible medication in the backyard which poses an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14
Type B
11/24/2023
Section Cited
CCR87303(e)(5)

1
2
3
4
5
6
7
87303(e)(5)Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to the following:
1. Purchase and ensure that all restroom showers have nonskit mats and send proof by due date.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above as there were no nonskid mats in the showers which poses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3