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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610369
Report Date: 09/05/2026
Date Signed: 09/05/2026 03:06:58 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/05/2026 03:06 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
Lookup Error,
, CA
FACILITY NAME:ALORA'S SENIOR HOMEFACILITY NUMBER:
197610369
ADMINISTRATOR/
DIRECTOR:		DE MATA, EVANGELINEFACILITY TYPE:
740
ADDRESS:23217 CUERVO DRIVETELEPHONE:
(661) 388-1524
CITY:VALENCIASTATE: CAZIP CODE:
91354
CAPACITY: 6CENSUS: 5DATE:
09/05/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:31 AM
MET WITH:Sunday Chukwudi - CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an annual required visit. LPA met with Sunday Chukwudi and Sara Mae Lulu, Caregivers and explained the reason for the visit. The administrator, Evangeline De Mata was out of town and staff made multiple attempts to contact them, but no response received. The facility cares for residents age range 60 and over, approved for (6) non-ambulatory, approved hospice waiver for (6). There are currently (5) residents residing in the home. LPA used the infection control tool to evaluate the facility. LPA did not utilize the Compliance and Regulatory Enforcement (CARE) for today's inspection as it is not available for the annual/random type of visit. The following were observed:
The facility is a single story home located in a residential neighborhood. It consists of (5) resident bedrooms, (1) staff bedroom, (2) bathrooms, living room with fireplace, dining area, backyard, attached garage with laundry area. There is also a dinette and a den for staff's use. The interior and exterior physical plant was inspected. LPA observed a fireplace with a freestanding screen which is not adequate to securely prevent residents access. Resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. The bathrooms were observed to be clean and operational; however, a recent water heater failure has left the entire home without hot water. Exit doors have auditory devices that were operating at the time of the visit. The kitchen was observed to have sufficient amount of perishable and non-perishable food supplies. One fire extinguisher mounted on the kitchen wall was serviced on 01/22/2026. Cleaning supplies and toxic substances are stored in a cabinet in the garage, but it was observed to be unlocked during the visit which makes it accessible to the residents. Water temperature readings were not measured due to the lack of hot water in the home. The facility is equipped with cameras in the common areas. The backyard has a shaded area and sitting area and there are no pools or large bodies of water. The side yard and backyard appeared to be used as outdoor storage for multiple used wheelchairs and miscellaneous items kept under tarp covers. Smoke detectors, fire sprinklers and pull fire alarm system observed and hard wired to the Fire Department.*****CONTINUED ON LIC809-C*****
David Sicairos
Bennette Pena
DATE: 09/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2026
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 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
Lookup Error,
, CA
FACILITY NAME: ALORA'S SENIOR HOME
FACILITY NUMBER: 197610369
VISIT DATE: 09/05/2026
NARRATIVE
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There are sufficient staff members that provide care and supervision to the residents. (4) Staff files were reviewed. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Administrator's certificate expired on 07/01/2026. LPA did not review staff training as S1 cannot locate the file in the facility. (2) out of (4) staff files reviewed did not have health screening on file. LPA reviewed (4) resident files, Admission Agreement, Physician's Report (including TB and Ambulatory Status), Consent for Medical Treatment, Residents Personal Property and Residents Personal Rights were observed. Facility provides internet services to all residents and have access to the facility's telephone. There is sufficient space to accommodate both indoor and outdoor activities. Sufficient food supply is stored in the kitchen and pantry area. LPA observed a jar of sauce in the food pantry with an expiration date of May 2026. There are no residents with special diets residing at this facility. During the review of the residents medications, LPA observed that the staff did not document the medication administration record (MAR) properly. Staff had administered the morning medications and ((3) residents MARs was not initialed/documented for verification. Additionally, staff #1/S1 admitted prepouring medications, and preparing them in small plastic containers labeled am/pm. The medications are centrally stored and he facility uses Medication Administration Record (MAR) to document medications are administered as prescribed by the Physician. LPA did not review the disaster drill and the Emergency Disaster and Mass Casualty Plan as S1 cannot locate the file. (3) out of (4) resident files reviewed lack the physician's authorization/order for half bed rail. There are no residents with prohibited health conditions.

Deficiencies cited and Technical advisories issued. Exit interview was conducted on the phone with the co-administrator, Christopher Mendoza and a copy of this report along with the appeal rights were provided to Sunday Chukwudi, Caregiver.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 09/05/2026 03:06 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/05/2026 at 01:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: ALORA'S SENIOR HOME
FACILITY NUMBER: 197610369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2026
Section Cited
CCR
87465(h)(4)

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87465 Incidental Medical and Dental Care...(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
This requirement is not met as evidenced by:
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Administrator to ensure that medications are not prepoured and/or transferred between containers. Administrator to re-train all staff about medication and Title 22 Regs. 87465. Administrator to submit the in service training log to CCLD/LPA by POC due date.
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Based on observation, interviews, records review, the Administrator did not comply with the section cited above in which medications for (5) of (5) residents are being prepared ahead of time daily by putting them in designated small plastic containers labeled am/pm and S1 admitted prepouring medications which poses an immediate health, safety or personal rights risk to residents in care.
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Type B
09/11/2026
Section Cited
CCR87465(c)(3)

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87465..Incidental Medical and Dental Care..(c) If the resident's physician has stated in writing that the resident... but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident..(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.
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Administrator shall submit a written plan stating how this deficiency will be corrected. Administrator shall conduct staff in-service training regarding proper medication documentation and submit the in service training log to CCLD/LPA by POC due date.
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Based on observation, interviews, records review, the Administrator did not comply with the section cited above in which S1 had confirmed administering the morning medications for (3) out of (5) residents and the MAR was not initialed/documented for verification which poses a potential health, safety or personal rights risk to residents 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/05/2026 03:06 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/05/2026 at 01:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: ALORA'S SENIOR HOME
FACILITY NUMBER: 197610369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/11/2026
Section Cited
CCR
87411(f)

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87411...Personnel Requirements – General..(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. ...e report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. ....Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
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Administrator shall ensure all employees have a health screening performed by a physician on file and ensure that Staff #2 obtains a health screening ASAP and proof shall be submitted to CCLD/LPA by POC due date


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Based on record review, the licensee did not comply with the section cited above in which Staff #2 did not have a health screening done upon hire and Staff #3 did not have the health screening form on file which posed a potential health, safety or personal rights risk to residents 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 09/05/2026 03:06 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/05/2026 at 02:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: ALORA'S SENIOR HOME
FACILITY NUMBER: 197610369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2026
Section Cited
CCR
87303(e)(2)

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87303..Maintenance and Operation..(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:
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Administrator confirmed that plumber has serviced the fixture and scheduled to come back today, 09/05/2026 to bring the parts and fix it. Administrator to send proof that the fixture has been fixed by sending receipt/invoice to CCLD/LPA by POC due date.
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Based on observation, the Administrator did not comply with the section cited above in which a recent water heater failure has left the entire home without hot water which poses a potential health, safety or personal rights risk to residents in care
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***Administrator stated that their back up plan is to boil water to provide warm water to residents.***

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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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 09/05/2026 03:06 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/05/2026 at 02:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: ALORA'S SENIOR HOME
FACILITY NUMBER: 197610369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2026
Section Cited
CCR
87608(a)(3)

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87608..Postural Supports..(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
This requirement is not met as evidenced by:
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Administrator to ensure that written orders from a physician indicating the need for bed rails shall be maintained in the residents' record. Administrator to submit the physician's order for (3) of (4) residents using 1/2 bedrail to CCLD/LPA by POC due date.
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Based on records review, the Administrator did not comply with the section cited above in which (3) out of (4) resident files reviewed did not have the physician's authorization/order for half bed rail on file which poses a potential health, safety or personal rights risk to residents 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2026


LIC809 (FAS) - (06/04)
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