Alora's Senior Home

Type of visit: Annual/Random

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***** 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.the state’s words, verbatim · CDSS document, Sep 5, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(4) · Plan of correction due date: Sep 7, 2026

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: 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.the state’s words, verbatim · CDSS document, Sep 5, 2026

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(c)(3) · Plan of correction due date: Sep 11, 2026

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. This requirement is not met as evidenced by: 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.the state’s words, verbatim · CDSS document, Sep 5, 2026

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(f) · Plan of correction due date: Sep 11, 2026

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. This requirement is not met as evidenced by: 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.the state’s words, verbatim · CDSS document, Sep 5, 2026

Plan of correction: 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

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Sep 7, 2026

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: 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 carethe state’s words, verbatim · CDSS document, Sep 5, 2026

Plan of correction: 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. ***Administrator stated that their back up plan is to boil water to provide warm water to residents.***

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Sep 18, 2026

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: 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.the state’s words, verbatim · CDSS document, Sep 5, 2026

Plan of correction: 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.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tuesday Cabiness conducted unannounced Annual Required inspection. LPA entered the facility and (3) staff where on duty. LPA informed staff the purpose of the visit, who contacted the Administrator, and arrived shortly after. Currently the facility’s census is (4), with (1) resident on hospice. LPA observed facility license and sketch, emergency disaster plan, grievance/complaint procedures, personal rights, rights of resident council, resident bill of rights, and emergency disaster plan visibly posted on the wall. LPA toured the physical plant inside and outside with staff. LPA inspected resident bedrooms, bathrooms, and common areas, to ensure there were no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility has (6) bedrooms, with (1) room for staff and (2) bathrooms. Inside temperature was comfortable, and LPA observed all areas to be clean and appropriately furnished for resident’s comfort and safety. LPA reviewed the food service and storage area, and it was observed to have a sufficient supply of perishable and nonperishable. The facility stores extra refrigerator in the garage, with fresh fruit, vegetables, and frozen meat. Storage areas for toxins, knives, and medication were locked and secured. Hot water temperature measured at 118.4 degrees Fahrenheit. Bathrooms are provided with soap, towels, non-skid mat, and grab bars were located by shower and toilet. Smoke and carbon monoxide detectors are hard-wired and were operating correctly. Fire extinguishers are fully charged. First aid kit had sufficient supplies and first aid manual. The backyard had clear passageways and free from obstruction, with gates easily accessible. Patio furniture area had comfortable table and chairs for residents. LPA checked centrally stored and medication records, and staff and resident files. Exit interview copy of report provided to Administrator.the state’s words, verbatim · CDSS document, May 6, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tuesday Cabiness conducted unannounced Annual Required inspection. LPA entered the facility and observed staff in the common area. LPA informed staff the purpose of the visit, who contacted the Administrator. LPA spoke to Administrator over the phone, who arrived shortly after. LPA checked personnel summary report to verify fingerprint or association clearance, and it was observed all staff is cleared. The facility is licensed to serve for (6) elderly residents, age (60) and over. Currently the facility’s census is (4), with (1) resident on hospice. LPA observed facility license and sketch, emergency disaster plan, grievance/complaint procedures, personal rights, rights of resident council, resident bill of rights, and emergency disaster plan visibly posted the wall; including COVID signs. LPA toured the physical plant inside and outside with staff. LPA inspected resident bedrooms, bathrooms, and common areas, to ensure there were no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility has (6) bedrooms, with (1) room for staff and (2) bathrooms. Inside temperature was comfortable, and LPA observed all areas to be clean and appropriately furnished for resident’s comfort and safety. LPA reviewed the food service and storage area, and it was observed to have a sufficient supply of perishable and nonperishable. The facility stores extra refrigerator in the garage, with fresh fruit, vegetables, and frozen meat. Storage areas for toxins, knives, and medication were locked and secured. Hot water temperature measured at 109.4 degrees Fahrenheit. Bathrooms are provided with soap, towels, non-skid mat, and grab bars were located by shower and toilet. Smoke and carbon monoxide detectors are hard-wired and were operating correctly. Fire extinguishers are fully charged. First aid kit had sufficient supplies including tweezers, scissors, thermometer and first aid manual. The backyard had clear passageways and free from obstruction, with gates easily accessible. Patio furniture area had comfortable table and chairs for residents. LPA checked centrally stored records, and medication records, and observed files had incomplete records and missing information. Resident and staff files reviewed, LPA observed missing training records, incomplete records and documents. This is a potential health and safety risk to residents in care. Citation and technical violations issued; exit interview copy of report, and appeal rights provided.the state’s words, verbatim · CDSS document, May 9, 2024