197607575-9-17-2024-29-AS-KLOZ-D9GTLA-20240926144913

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607575
Report Date: 09/17/2024
Date Signed: 09/17/2024 05:07:52 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
09/10/2024 and conducted by Evaluator Trevor Byrne

COMPLAINT CONTROL NUMBER: 29-AS-20240910144537

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:	09/17/2024
		UNANNOUNCED	TIME BEGAN:	09:46 AM
MET WITH:	Mariana Romano		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff do not provide adequate care and supervision to a resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced 10-day complaint visit to investigate the above allegation. LPA arrived to the facility at 09:46 AM and was greeted by facility staff. Staff contacted Mariana Romano, Administrator, via telephone call. The Administrator arrived at 09:51 AM, entrance interview conducted and the reason for the visit was explained.

During today's visit, starting at 09:52 AM, the LPA along with the facility Administrator conducted a brief physical plant tour. The LPA also conducted interviews with residents, staff, and administrator between 10:30 AM and 11:40 AM and obtained copies of pertinent records.
During the physical plant tour, LPA observed all facility exits to contain functioning auditory alarms. The facility has an appropriately screened pool in the backyard. The facility has a camera near the front door to the house that has clear line of sight to the front gate.
Continued on 9099C.

Substantiated

Estimated Days of Completion: 7

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor Byrne	TELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 29-AS-20240910144537

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: 09/17/2024

NARRATIVE

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The allegation of ‘Staff do not provide adequate care and supervision to a resident’ alleges Resident #1 (R1) was observed to be wandering outside the facility without the presence of staff. The Reporting Party also provided video evidence of R1 outside of the facility without staff present which allegedly occurred on 09/03/2024. Record review revealed that R1 was admitted to the facility in August 2023. R1’s physician’s report indicates R1 cannot leave the facility unassisted due to a diagnosis of dementia. Interviews with residents and staff revealed that R1 has, in the past, left the facility without the assistance of a caregiver. Previously on 07/09/2024, the Department received a complaint, (CONTROL NUMBER 29-AS-20240709121224) alleging staff do not provide adequate care and supervision to R1, as R1 was observed to be wandering outside of the facility unassisted. The allegation was substantiated on 07/11/2024. The Administrator’s plan of correction for the deficiency was to install auditory alarms on facility exits, schedule walks for R1 with the supervision of a caregiver, swap R1’s coffee to decaf, and Increase R1’s inhouse activities.

During today’s inspection, the LPA showed the Administrator the video of R1 allegedly being outside of the facility without supervision on 09/03/2024. The Administrator confirmed the person in the video was R1 but stated they were unaware R1 was outside of the facility without staff supervision. During the inspection, the LPA did observe the presence of two caregivers, of which one caregiver being assigned as R1’s 1:1 caregiver. During the interview with Staff #1 (S1) they confirmed they are R1’s 1:1 caregiver although they stated they have been working as R1’s 1:1 caregiver for “One month, couple of months.” R1 stated that S1 had been their caregiver since “last week, maybe the week before.” Based on the interviews conducted, evidence submitted, and file review, there is sufficient evidence to support to the allegation that staff do not provide adequate care and supervision to a resident. Therefore, the allegation of staff do not provide adequate care and supervision to a resident is deemed Substantiated at this time.

LPA informed the Administrator that they had been cited on 07/11/2024 at a previous complaint visit (CONTROL NUMBER 29-AS-20240709121224) for failing to follow the same regulation. As this is a repeat violation of the same section of Title 22 Regulations [HSC 1569.312(a)] within last 12 months a civil penalty of $250 is being assessed. LPA informed administrator that failure to correct the deficiency may lead to additional civil penalties.

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

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor Byrne	TELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240910144537

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: 09/17/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/18/2024 Section Cited HSC 1596.312(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: Based on interviews conducted, evidence submitted and file review, the licensee did not comply with the section cited above.	1 2 3 4 5 6 7	Licensee will provide the Department with a staff schedule outlining the hours worked of resident #1's 1:1 caregiver and a written plan of action outlining the actionable changes the facility will take to prevent resident 1's elopement behavior.
	8 9 10 11 12 13 14	Facility staff failed to provide the necessary care and supervision to Resident #1 which allowed Resident #1 to elope from the facility unassisted, which poses an immediate 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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor Byrne	TELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC9099 (FAS) - (06/04)

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