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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607575
Report Date: 07/28/2021
Date Signed: 07/28/2021 04:56:40 PM

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:
07/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:MARIANA ROMANOTIME COMPLETED:
04:55 PM
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At 2:55 pm, Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by Administrator, MARIANA ROMANO. This annual had a specific emphasis on infection control practices and procedures. At 3:20 pm, LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

OUTDOOR SPACE: LPA observed the front patio, which has a covered outdoor area for resident use. There is a self-latching gate on the side of the house designated for an emergency exit. There is a gated pool in the backyard, which was locked.

KITCHEN: At 3:25 pm, LPA observed the kitchen/dining area. Knives are stored in a locked cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Hot water measured at 105.1-degree Fahrenheit. Medications and first aid kit were locked in a cabinet in the kitchen.

BEDROOMS: LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: Resident restroom is clean and sanitary and in operating condition with grab bars and non-skid mat. Hot water measured at 108.2-degree Fahrenheit.

COMMON AREAS: LPA observed common area to be relatively clean and properly furnished. At 3:30 pm, LPA observed staff preparing dinner. LPA observed the fire extinguisher to be fully charged and last serviced on 04/27/2021. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LLC
FACILITY NUMBER: 197607575
VISIT DATE: 07/28/2021
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INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station.

LPA observed a 30-day supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

The following recommendations were made:

- Posting Provider Information Notices (PINs) and educating staff, residents, and families on changing policies and procedures from the Department.

- An Advisory note issued for ensuring that staff complete the fit testing for the N95 respirator.

Between 3:00 pm - 4:30 pm, LPA conducted Infection Control mitigation module with Administrator.

LPA will provide Administrator with information and resources to have all staff fit tested for N95 respirators.

Exit interview conducted. Report issued and a copy of the report will be provided via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
LIC809 (FAS) - (06/04)
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