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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607575
Report Date: 07/11/2024
Date Signed: 07/11/2024 03:50:55 PM


Document Has Been Signed on 07/11/2024 03:50 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: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: 3DATE:
07/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:02 PM
MET WITH:Mariana RomanoTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst(LPA) conducted an unannounced case management visit due to the deficiency noted during a visit to the facility today. LPA Yee met with Mariana Romano and the reason for today's visit was explained.

During today's visit to the facility to investigate a complaint, LPA Yee observed that all 5 outside exiting doors were not equipped with any auditory devices to alert staff when residents exit the facility. The facility accepts and retains clients with dementia.


Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview was conducted, Appeals Rights discussed and a copy was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
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 2


Document Has Been Signed on 07/11/2024 03:50 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: TOLUCA LAKE MANOR SENIOR ASSISTED LIVING LLC
FACILITY NUMBER: 197607575

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2024
Section Cited
CCR
87705(j)

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Care of Persons with Dementia: The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement was not met as evidenced by: All 5 outside exiting doors were not equipped with auditory
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Licensee will ensure that all outside exiting doors are equipped with an operational auditory device to alert staff when residents exit the facility. Monthly checks will also be performed to ensure the batteries are operational. Provide evidence that the doors
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devices, which poses a potentional health and safety risk to the residents in care.
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have been equipped with auditory device by 7/18/24.

****Auditory devices were installed on all 5 doors at the time of the visit*****

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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: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2