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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850262
Report Date: 11/30/2023
Date Signed: 11/30/2023 05:14:01 PM


Document Has Been Signed on 11/30/2023 05:14 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: 2DATE:
11/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Tsiana Mikia, StaffTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Emily Peraldi, along with WISE and Healthy Aging Long-Term Ombudsman Program (LTCO) Regional Director Ginger Perini conducted an unannounced visit at the above location. At 4:00 p.m., the LPA met with staff and explained the reason for the visit. At 4:19 p.m., the LPA spoke with the Licensee Representative Pogos Tofalyan. The Licensee Representative was not available to meet the LPA and authorized staff, Tsiana Mikia to sign the report.

The purpose of the visit is to ensure there are no health and safety hazards. Starting at 4:02 p.m. LPA Peraldi and Ombudsman toured the facility and spoke with two (2) residents. At 4:03 p.m., the LPA observed a slide latch lock on the front door. At 4:07 p.m., the LPA observed the kitchen and observed insufficient supply of perishable and non-perishable food.

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: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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Document Has Been Signed on 11/30/2023 05:14 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: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2023
Section Cited
CCR
87468.1(a)(6)

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87468.1(a)(6) Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following...(6) To leave or depart the facility at any time and to not be locked into any..., building...This requirement is not met as evidenced by:
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The Licensee has agreed to do the following:
1. Remove the slide latch lock from the front door.
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Based on observation, the licensee did not comply with the section cited above, as the front door had a slide latch lock which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
12/01/2023
Section Cited
CCR87555(b)(26)

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87555(b)(26)General Food Service Requirements(b) The following food service requirements...(26) Supplies of nonperishable foods for a minimum of one week &perishable foods for a minimum of two days shall ...This requirement is not met as evidenced by:
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The Licensee has agreed to do the following:
1. Go grocery shopping and ensure that the facility has insufficient supply of perishable and non-perishable food and send proof to the Department.
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Based on observation the licensee did not comply with the section cited above as many the facility had insufficient supply of perishable and non-perishable food which poses an immediate health, safety or personal rights risk to persons in care.
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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