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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607575
Report Date: 10/01/2024
Date Signed: 10/01/2024 11:35:36 AM


Document Has Been Signed on 10/01/2024 11:35 AM - 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:
10/01/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Marianna RomanoTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced plan of correction (POC) case management visit to the facility above. The reason for this visit was to conduct a follow-up in reference to deficiencies that were cited during a complaint investigation (Complaint Control Number: 29-AS-20240910144537) that occurred on 09/17/2024. The LPA met with facility staff member Abdul Kadir, at 10:17 AM and explained the purpose of the visit. Facility staff contacted the facility administrator Marianna Romano who arrived at the facility at 10:20 AM. Entrance interview conducted and the reason for the visit was explained.

During today’s visit LPA Byrne interviewed the facility administrator. The facility administrator stated that they have contacted a physician’s assistant to update resident 1’s (R1) physician’s report. The facility administrator also stated that R1 is scheduled for a psychological evaluation sometime next week. During the visit Administrator contacted Good Choice Home Health and asked them to provide the updated physician’s report for R1. The document that was received was a Home Health Certification and Plan of Care form and not an updated physician’s report. The document provided did not satisfy the requirements of the POC.

The facility administrator was advised during the original complaint investigation that failure to correct deficiencies would lead to additional penalties. The facility administrator did not provide the LPA with the required documentation within the appropriate timeframe. As this is a failure to correct the POC within the given timeframe and no extension was requested a civil penalty is being assessed in the form of $700. The total of the civil penalty is calculated at $100 per day starting after the due date of the POC. The POC for this deficiency was due on 09/25/2024 and today’s date is 10/01/2024. LPA informed administrator that failure to correct the deficiency may lead to additional penalties.

Exit interview conducted, civil penalty assessed, and a copy of the report delivered.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024
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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