197607575-7-11-2024-29-AS-KHEN-D7Q7B9-20240731213044

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607575
Report Date: 07/11/2024
Date Signed: 07/11/2024 03:47:07 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/09/2024 and conducted by Evaluator Christine Yee

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20240709121224

FACILITY NAME:	TOLUCA LAKE MANOR SENIOR ASSISTED LIVING LLC		FACILITY NUMBER:	197607575
ADMINISTRATOR:	MARIANA ROMANO		FACILITY TYPE:	740
ADDRESS:	4560 CARTWRIGHT AVE.		TELEPHONE:	(818) 232-7338
CITY:	TOLUCA LAKE	STATE: CA	ZIP CODE:	91602
CAPACITY:	6	CENSUS: 3	DATE:	07/11/2024
		UNANNOUNCED	TIME BEGAN:	10:03 AM
MET WITH:	Mariana Romano		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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1. Staff do not provide adequate care and supervision to a resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced complaint visit to investigate the above allegation and was let into the facility by Stella Cardoza, Staff. Staff contacted Mariana Romano, Administrator, via telephone and she arrived at 10:31am to conduct the visit. Also present on today's visit was Sylvana Ramirez, Staff. LPA Yee explained the reason for today's visit.

On today's visit, LPA Yee conducted an interview with Mariana Romano at 10:35am, Staff #1 at 11:52am and a telephone interview with Witness #2 at 11:34am. A written statement from Witness #1 was also obtained prior to today's visit.

Per information obtained from the interviews conducted, Resident #1 was admitted to the facility in October 2023. Per interview with the Administrator, Resident #1, started leaving the facility recently and wandering

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240709121224

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 07/11/2024

NARRATIVE

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into the neighbors' yards and collecting dried leaves, fallen flowers, rocks, twigs and going into neighbors trash cans and taking out discarded items such vases and picking up discarded furniture and taking it back to the facility. Resident #1 elopes very fast from the facility in bare feet and without the staff's knowledge. Resident #1 sustained a foot injury as a result of wandering around barefooted. Per interviews conducted with the Administrator, Resident #1 would elope for only a few minutes before staff realizes that Resident #1 is gone and they will look for her and bring her back. Upon inquiry about auditory devices on all 5 outside exiting doors, the Administrator admitted they used to have them on the doors but they were removed. Per statement received from Witness #1, they have observed Resident #1 alone on multiple occasions , wandering around in the neighborhood collecting leaves, rocks, flowers and un-escorted. Per review of Resident #1's file, the physician has determined that Resident #1 is not able to leave the facility unassisted. Per interview with Witness #2, they arrived at the facility on 7/9/24 for a visit and saw Resident #1 rummaging through the trash cans placed outside the facility with staff close by re-directing the resident. Resident #1 was observed with dirty nails and matted hair. Per interviews conducted, Resident #1 refuses to shower and refuses to have the injured foot treated. Witness #2 also believes that Resident #1 may have also shoved a staff. Per the Administrator, due to this unusual behavior, she has had a discussion with Resident #1's conservator and social worker and they all agreed that Resident #1 be sent to the hospital to be assessed for possible infection and medication adjustment. Resident was taken to the emergency room by the Administrator on 7/10/24 and was still hospitalized as of today's visit. Witness #2 confirmed that upon discharge, arrangements have been made to relocate Resident #1 to the facility's sister facility.

Based on the interviews conducted and file review, there is sufficient evidence to support to the allegation that staff do not provide adequate care and supervision to a resident.

Deficiencies cited under Health and Safety Code, Title 22, Division 6, Chapter 3.2

Exit interview was conducted, Appeals Rights discussed and a copy was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20240709121224

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HSC 1569.312(a)	1 2 3 4 5 6 7	Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: interviews conducted and file review, the licensee did not comply with the section cited above. Facility	1 2 3 4 5 6 7	Licensee will provide the Department with a written plan of action that will be implemented to ensure that all residents are provided with the appropriate level of care and supervision based on the needs identified in their care plan by 7/18/24.
	8 9 10 11 12 13 14	staff failed to provide the necessary care and supervision which allowed Resident #1 to easily elope from the facility on multiple occasions which posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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