197610369-5-17-2023-31-AS-TCAS-CRWTYQ-20230517150906

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610369
Report Date: 05/17/2023
Date Signed: 05/17/2023 03:09:53 PM

Document Has Been Signed on 05/17/2023 03:09 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ALORA'S SENIOR HOME		FACILITY NUMBER:	197610369
ADMINISTRATOR:	DE MATA, EVANGELINE		FACILITY TYPE:	740
ADDRESS:	23217 CUERVO DRIVE		TELEPHONE:	(661) 388-1524
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91354
CAPACITY:	6	CENSUS: 4	DATE:	05/17/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Christopher Mendoza		TIME COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a PRE-LICENSING visit to the above address 23217 Cuervo Drive, Valencia, CA 91354. LPA met with Co-Administrator Christopher Mendoza. The inspection included, fire safety, personal accommodations, building and grounds, furniture/equipment, food service, and medication. Fire Inspection was approved on March 22, 2023 which met fire department requirements. The application did not specify an approval for hospice, and currently the facility has (2) residents on hospice. LPA informed Co-Administrator to contact the application unit regarding the hospice waiver. Note, this inspection is a change of ownership; with the previous licensee who was approved for hospice. Facility sketch, emergency disaster plan, complaint procedures, personal rights, emergency exit plan, and other required Licensing were visibly posted. COVID signs, visitor book, and hand washing station observed at the front entrance.

The physical plant was toured inside and out with Co-Administrator Chris. The facility is a one level home, with (6) bedrooms with (2) bathrooms; (1) room is for staff and (1) room is shared. Food supply was inspected and observed, and storage areas, cabinets, pantries, cupboards counters, and refrigerator were clean and appropriate for food preparation. Knives and medication were stored in cabinets located in the kitchen area. Appliances were clean and functional, and utensils, plates, and cups were in good repair. Cleaning supplies, poisons, toxins and chemicals were locked and stored in the garage area. There was enough supply of linens and towels, which were stored in a cabinet located in the hallway. Hygiene products were also available, which were locked and secured. LPA observed at least (30) day supply of PPE.

The common areas included the dining, living, bathroom, and bedrooms. Doors and passageways were clear and unobstructed. Walls, ceilings, floors, window screens and all other rooms were clean, in good repair, and appropriately furnished. Resident rooms observed to have a mattress with pad, sheets, pillow, bedspread, dresser, closet space, and chair.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALORA'S SENIOR HOME	FACILITY NUMBER: 197610369
	VISIT DATE: 05/17/2023

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Bathrooms were clean had functional fixtures, with soap and towels, non-skid mats, grab bars and hand washing signs were posted. The water temperature was checked. The back yard is completely fenced with a gate easily accessible and unlocked. There are no swimming pools or other bodies of water, no visible hazards around the surrounding grounds. Patio furniture available for resident's use.

Smoke detectors and carbon monoxide were hardwired and operating. Fire extinguisher is fully charged. Telephone service already operating from previous owners. First aid kit inspected. Staff/client files and medication locked and secured. .

COMP III discussed and infection plan.

Exit interview conducted and copy of report provided to Co-Administrator.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

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