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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197607575
Report Date:
08/17/2023
Date Signed:
08/17/2023 06:28:10 PM
Document Has Been Signed on
08/17/2023 06:28 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 NORTH
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
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:
5
DATE:
08/17/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:25 AM
MET WITH:
Mariana Romano, Administrator
TIME COMPLETED:
06:35 PM
NARRATIVE
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. LPA Yee was given entry into the home by Joel Senga, Staff. Byanca Flores, another staff arrived around 9:41 am. Mariana Romano, Administrator was contacted by Staff via telephone and she arrived at 9:56am to conduct the visit.
The facility is a single storey family home consisting of a living room, dining room, kitchen, sun room, 4 bedrooms, 2 full bathrooms and a attached garage that was converted in 2018-2019 without notification to the Department. Per Licensee, she obtained permits from the city. Located in the backyard is a swimming pool enclosed with a 5 feet fence.
The following were observed on today's visit.
upon arrival at the facility, LPA Yee was let into the facility by a Joel Senga. Per information provided by Joe, it was his first day at the facility and per the Administrator, he is an applicant for a caregiver position. However, there were no other staff present at the facility other than then Joel. Per Joel, the regular staff, Byanca Flores had stepped out and she was observed returning at 9:41am
per information obtained on today's visit, the facility had converted the attached garage to a studio without notifying the Department and has not been fire cleared for use by residents. The city also assigned a new address to the conversion - 4558 Cartwright Avenue. The Administrator was advised that the resident needs to be moved back into the facility until the conversion is fire cleared by the fire department. Per the Administrator, the resident would be relocated to Bedroom #1 as of tonight. A copy of the permit for the conversion will be provided by the Licensee by 8/24/23.
Food was reviewed and there was sufficient perishable foods for 2 days and insufficient non-perishable foods for 7 days observed on the premises.
Continued on LIC809-C
SUPERVISOR'S NAME:
Jeralyn Ann Pfannenstiel
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
08/17/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
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Document Has Been Signed on
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- 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 NORTH
,
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:
08/17/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
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 in 1 out of the 2 bathroms tested for the water temperature, the water temperature in the bathroom located by bedroom #4 read 98.8 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/18/2023
Plan of Correction
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The Licensee will adjust the thermostat of the water heater to ensure that the water termperature meets Title22 requirement of 105 - 120 degrees Fahrenheit. Licensee will self certify that the water temperature was adjusted and in within the required range by 8/18/23
Type A
Section Cited
CCR
87307(e)
Personal Accommodations and Services
(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means.
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 in all counts. The gate was visually observed to be secured with a chain and a padlock, however on closer inspection, the chain that secured the gate could easily be slipped off the post without the need of a key and this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/18/2023
Plan of Correction
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The Licensee will ensure that the gate to the swimming pool is secured with a locking method that does not permit the gate to be opened by the residents as this poses an immediate danger to the residents in care. Provide evidence that the gate is made inaccessible to the residents by 8/18/23
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:
Jeralyn Ann Pfannenstiel
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
08/17/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/17/2023
LIC809
(FAS) - (06/04)
Page:
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Document Has Been Signed on
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- 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 NORTH
,
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:
08/17/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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 in 1 out of 1 count of cabinets check, the licensee did not ensure that the cabinet under the kitchen sink that contains the cleaning and disinfecting solutions that was visually observed to be secured by a chain and padlock but did not ensure that the chain could not be slipped off the knobs which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/18/2023
Plan of Correction
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The Licensee will provide LPA with a plan and a method as to how the cleaning and disinfecting solutions will be made inaccessible to the residients. by 8/18/23
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
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 in 1 out of 4 staff observed at the facility, Joel Senga, prospective caregiver was observed alone and providing care to residents at the facility and he did not have a criminal record clearance to be present at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/18/2023
Plan of Correction
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Licensee will provide a written plan of action to the Department as to how the facility will ensure that all staff have a criminal record clearance and are also associated to the facility by 8/18/23
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:
Jeralyn Ann Pfannenstiel
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
08/17/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/17/2023
LIC809
(FAS) - (06/04)
Page:
3
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Document Has Been Signed on
08/17/2023 06:28 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 NORTH
,
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:
08/17/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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 backyard and along the side of the home was observed with unstored ladders, mops, brooms, discarded items which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/24/2023
Plan of Correction
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Licensee will conduct general cleaning of the outside areas and ensure that all discarded items are removed and that all ladders, mops, brooms and any unused item is stored away by 8/24/23
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.
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 in 2 our of 2 counts of screens inspected, it was observed that the screen by the kitchen table had holds in the screen and the screen on the sliding screen door in bedroom #3 was ripped which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/24/2023
Plan of Correction
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Licensee will inspect all the facility windows and doors that have screens to ensure that the screens are in good condition and will conduct repairs if they are ripped by 8/24/23
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:
Jeralyn Ann Pfannenstiel
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
08/17/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/17/2023
LIC809
(FAS) - (06/04)
Page:
4
of
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Document Has Been Signed on
08/17/2023 06:28 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 NORTH
,
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:
08/17/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87204(b)
Limitations -Capacity and Ambulatory Status
(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Error
POC Due Date:
08/17/2023
Plan of Correction
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Error
Type B
Section Cited
CCR
87308(c)
Resident and Support Services
(c) General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observationthe licensee did not comply with the section cited above since the sun room was being used to store , resident diapers, dog food, plastic containers, foldable bed, toiletries, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/24/2023
Plan of Correction
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The Licensee will submit a plan as to how the facility will ensure that all resident supplies and equipment are stored and does not interfere with the residents' use of the sun room by 8/24/23
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:
Jeralyn Ann Pfannenstiel
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
08/17/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/17/2023
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
08/17/2023 06:28 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 NORTH
,
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:
08/17/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87413(a)(1)
Personnel - Operations
(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation the licensee did not comply with the section cited above the residents were left alone with Joe Senga, prospective hire as caregiiver while regular staff stepped out of the facility to do an errand, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/24/2023
Plan of Correction
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LIcensee will provide a written ands signed plan of action to ensure that the residents are always supervised by trained staff and not left alone with individuals that have not been trained to provide care to the residents by 8/24/23
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:
Jeralyn Ann Pfannenstiel
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
08/17/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/17/2023
LIC809
(FAS) - (06/04)
Page:
6
of
8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
TOLUCA LAKE MANOR SENIOR ASSISTED LIVING LLC
FACILITY NUMBER:
197607575
VISIT DATE:
08/17/2023
NARRATIVE
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Water temperature taken in the common bathroom located by Bedroom #4 read 98.8 degrees Fahrenheit and the reading in the common bathroom located by bedroom #3 read 107 degrees Fahrenheit.
Fire extinguisher located in the kitchen was serviced on 4/25/23
All 4 resident bedrooms had the required Title 22 furniture except bedroom #4 was not observed with a night stand.
The pool was observed surrounded by a 5 feet fence but the lock on the gate was not secured and entry to the pool area was not made inaccessible to the residents in care.
Due to time constraints any deficiencies not cited on today's visit will be addressed on a return visit.
Licensee provided the following documents on today's visit:
an LIC200 - Application
revised facility sketch
a copy of the inspection report for the conversion of the garage.
the permit number obtained for the garage conversio
Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8
Exit interview was conducted, APPEALS RIGHTS DISCUSSED and a copy given
SUPERVISOR'S NAME:
Jeralyn Ann Pfannenstiel
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/17/2023
LIC809
(FAS) - (06/04)
Page:
8
of
8
Document Has Been Signed on
08/17/2023 06:28 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 NORTH
,
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:
08/17/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
87555 General Food Service Requirements
(b) The following food service requirements shall apply:
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation the licensee did not comply with the section cited above, per review of the facility food] there was sufficient perishable foods for 2 days but insufficient non-perishable foods observed in the pantry] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/18/2023
Plan of Correction
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Licensee will purchase additional non-perishable foods to supplement the food already in the facility to bring the food quantities required by Title 22. Ensure that the items purchased will provide a balance meal consisting of a vegetable, protein and a carbohydrate by 8/18/23
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Jeralyn Ann Pfannenstiel
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
08/17/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/17/2023
LIC809
(FAS) - (06/04)
Page:
7
of
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