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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607575
Report Date: 08/05/2024
Date Signed: 08/05/2024 03:58:55 PM


Document Has Been Signed on 08/05/2024 03:58 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: 4DATE:
08/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Mariana RomanoTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 10:22 AM. LPA was greeted by Facility staff who contacted the facility administrator Mariana Romano. Facility administrator arrived to the facility at approximately 10:28 AM Entrance interview conducted.
Beginning at 10:28 AM, the LPA, along with facility administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. A camera was observed in the Living room. The LPA observed the fire extinguisher to be fully charged and serviced on 03/08/2024. At 10:30 a.m. LPA observed an unlocked cabinet that contained a prescription Ipratropium bromide and albuterol sulfate inhaler box. Smoke detectors and carbon monoxide detectors were tested at 01:01 p.m. and were functional at the time of the visit.

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food and emergency water. The LPA observed one designated drawer where knives and sharps are stored locked and inaccessible to residents. At 10:45 a.m. LPA observed expired condiments located in the refrigerator.

BATHROOMS: There are two (2) bathrooms for resident use. Bathrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed next to all toilets and in all showers and all were properly secured. The water temperature was measured between 105.4 and 106.7 degrees Fahrenheit, which is in compliance with regulation. Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
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 9


Document Has Been Signed on 08/05/2024 03:58 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: 08/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as a perscription medication inhaler was unsecured in a kitchen cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2024
Plan of Correction
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Medication was removed at the time of the visit POC cleared.
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as a resident that was identified as bedridden by their physician resides in a room that is not designted in the facility's fire clearance as a bedridden approved room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2024
Plan of Correction
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Licensee will move the resident to the appropriate bedridden room and submit proof to CCL no later than POC due date.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/05/2024 03:58 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: 08/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one (1) employee file was missing their health screening which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
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Licensee will submit an appropriate health screening to CCL no later than POC due date.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the kitchen contained expired food items which poses a potential health risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
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Licensee will check all facility food and will dispose of all expired items. Licensee will submit proof of disposed food to CCL no later than POC due date.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 9


Document Has Been Signed on 08/05/2024 03:58 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: 08/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (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:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as two (2) out of two (2) resident files did not contain PRN medication logs which poses a potential health risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
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Licensee will submit proof of PRN logs for both residents to CCL no later than POC due date.
Type B
Section Cited
CCR
87615(a)(5)
Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based onrecord review, the licensee did not comply with the section cited above as one (1) resident was identified by their physician as total care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
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Licensee will have the resident reappraised by their physician to accurately reflect their capabilities. Licensee may submit appropriate documentation to CCL to obtain a exception to retain a total care resident.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
LIC809 (FAS) - (06/04)
Page: 4 of 9


Document Has Been Signed on 08/05/2024 03:58 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: 08/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
(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. A report shall be made of each screening, signed by the examining physician. The 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. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. 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:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one (1) staff member had a positive intradermal TB test and no chest x-ray which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2024
Plan of Correction
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Licensee will submit proof of a negative chest X-ray to CCL no later than POC due date.

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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
LIC809 (FAS) - (06/04)
Page: 8 of 9


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
VISIT DATE: 08/05/2024
NARRATIVE
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Continued from LIC 809-C

BEDROOMS: There are four (4) bedrooms in the facility; all four (4) are designated for resident use. One (1) staff room is designated as an ADU attached to the property that has a different address from the facility. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.



OUTDOOR SPACE: The backyard has sufficient patio furniture including shaded tables and chairs for resident use. An outdoor pool was observed to be appropriately screened. One outdoor shed was observed to contain pool care equipment. Facility has two exit gates, LPA observed clear passageways for emergency exit use.

RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Resident 1’s (R1) file identified them as a bedridden patient. R1 currently resides in a room that is not approved in the facility’s fire clearance for bedridden residents. Staff 1’s (S1) file contained a positive TB test. No chest x-ray was present at the time of the file review.

MEDICATION REVIEW: Medications for 2 (two) of four (4) residents were observed. All medications reviewed were documented properly on their centrally stored medication and destruction record sheet. PRN medication administration was not logged at the time of medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Last emergency disaster drill was conducted 06/01/2024. The facility’s emergency disaster plan is up to date and adequate.

INTERVIEWS: LPA interviewed two (2) staff and two (2) residents. One resident stated that the food is sometimes cold. One resident stated that they enjoy the amount of activities offered. All residents stated that staff treat them well and are attentive to their needs. Both staff were knowledgeable on resident rights, the different forms of abuse, and their roles and responsibilities. Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
LIC809 (FAS) - (06/04)
Page: 7 of 9
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
VISIT DATE: 08/05/2024
NARRATIVE
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Continued from LIC 809-C

During today’s visit LPA obtained a copy of the facility’s updated LIC500 and liability insurance.

The following deficiencies were observed (See LIC 809-Ds) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Licensee was advised that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
LIC809 (FAS) - (06/04)
Page: 9 of 9