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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607575
Report Date: 07/07/2021
Date Signed: 07/08/2021 09:41:17 AM

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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:TOLUCA LAKE MANOR SENIOR ASSISTED LIVING LLCFACILITY NUMBER:
197607575
ADMINISTRATOR:MARIANA ROMANOFACILITY TYPE:
740
ADDRESS:4560 CARTWRIGHT AVE.TELEPHONE:
(818) 232-7338
CITY:TOLUCA LAKESTATE: CAZIP CODE:
91602
CAPACITY:6CENSUS: 4DATE:
07/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Mariana RomanoTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Angel Ascencio conducted an unannounced case management visit. LPA met with Administrator Mariana Romano. Reason for visit was due to Mitigation Plan not being submitted.

As admin walked in the door, copy of the mitigation plan was provided to LPA. LPA collected a copy of the mitigation plan for review. LPA toured the physical plant areas inside and outside at 11:20 AM to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

Exit interview was conducted with Administrator, and a hard copy was provided via email for signature and Appeal Rights provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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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