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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607575
Report Date: 09/22/2022
Date Signed: 09/22/2022 02:09:55 PM

Document Has Been Signed on 09/22/2022 02:09 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
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:
09/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Mariana RomanoTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management Deficiencies visit due to deficiencies observed during a complaint inspection on this day. The LPA met with the Administrator Mariana Romano and explained the reason for the visit.

At 10:38 AM the LPA observed an unlocked cabinet with Pepto Bismo, various creams, old medications, and other misc. medical items.

At 11:04 AM, the LPA observed DayQuil, NyQuil, and vitamins in a resident room.

At 11:09 AM, the LPA observed the medications cabinet to be unlocked.

The following deficiency was cited from the CA Code of Regulation. See LIC 809-D. Exit interview and report reviewed with the Administrator. A copy of the report and appeal rights were emailed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2022
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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Document Has Been Signed on 09/22/2022 02:09 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 09/22/2022 at 12:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 09/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2022
Section Cited
HSC
87465(h)(2)

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87465 Incidental Medical and Dental Care (h)(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:
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The items were secured during the inspection. Plan of correction cleared.
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Based on observation, the licensee failed to comply with the section cited above as medications were observed unlocked and accessible to residents which is a health and safety risk to residents in care.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022


LIC809 (FAS) - (06/04)
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