197607575-8-30-2023-29-AS-KHEN-CW3RWP-20230927132329

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607575
Report Date: 08/30/2023
Date Signed: 08/30/2023 04:55:59 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
08/24/2023 and conducted by Evaluator Christine Yee

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20230824102537

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:	08/30/2023
		UNANNOUNCED	TIME BEGAN:	09:22 AM
MET WITH:	Mariana Romano, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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1. Staff did not seek medical attention for a resident in care.
2. Staff administered sleeping pills to resident to induce sleeping.
3. Staff did not properly manage residents medications.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced complaint visit to investigate the above allegations and met with Mariana Romano, Administrator. The reason for today's visit was explained.

On today's visit, LPA Yee conducted interviews with Mariano Romano, Administrator at 9:35am, Staff# 1 at 11:57am, Staff # 2 at 12:15pm and Staff #3 via telephone at 12:56pm. Resident#1's medication was reviewed at 12:51pm. Copies of Resident #1's file was obtained at 1:35pm.

Per information received from interviews conducted regarding allegation #1 - staff did not seek medical attention for a resident in care, facility staff indicated that the facility policy is that when a resident is observed to need medical attention such as choking or has fallen, have low oxygen level, they are to call 911 for emergency services and then notify the Administrator. However, per the Administrator, she is always

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230824102537

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/30/2023

NARRATIVE

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at the facility and she is usually the person who calls 911. Staff #1 indicated that they have never called 911 but knows that they are to call 911 if there is an emergency. Staff #1 through Staff #3 have all indicated that they have not been threatened or or known any staff who was threatened for calling 911. Per information provided by the Administrator, on 7/30/23, Resident #1 had low oxygen level but not severe enough to contact 911. Resident's family member scheduled an appointment with Resident #1's physician on 8/2/23 to address the reason for the low oxygen level and reason why the resident was not eating and looked "out of it" per staff. On the 8/2/23 visit, the physician issued a prescription for a half bed rail to prevent falls and oxygen. On the afternoon of 8/28/23 Resident #1 was observed with low oxygen levels and per contact with the resident's physician, 911 was called and Resident #1 was transported to the hospital. Lab work was performed and the resident was discharged back the home before the results were obtained. The facility was contacted on the morning of 8/29/23 with the results of the lab work. The lab results came back clean except for the blood culture. The resident had a bacterial infection in the blood. Oral antibiotics were prescribed. Per the Administrator, she made contact with the pharmacy to check on the status of the antibiotics on 8/29/23 and a follow up call was going to be made today. The antibiotics were delivered during today's visit at 10:14am. Per information provided on today's visit, there was insufficient evidence to establish that staff did not seek medical attention for Resident #1.

Allegation #2 - Staff administered sleeping pills to resident to induce sleeping. Per interviews conducted with the Administrator, Resident #1 does not have any sleeping pills. Resident #1 is prescribed a daily dose of Lorazepam 0.5 milligrams at night for anxiety. Resident #1 gets restless at night. Per interviews conducted with staff, the residents are given their medications in the morning and in the evening. The Administrator prepares the medications in a plastic container in the morning and in the evening and the staff give it to the residents. Per staff, they have not dispensed or observed anyone dispensing additional medications to Resident #1. The Lorazapem 0,5 milligrams, filled on 8/2/23 was counted at 12:51pm and 28 pills were in the bottle. Per information received on today's visit, there was insufficient evidence to conclusively establish that the resident was being provided with sleeping pills or additional medications to make Resident #1 sleep all day.

Allegation #3 - Staff did not properly manage residents medications. Per interview with the Administrator, residents are given their medications as prescribed. She adheres and dispenses medications to the residents as noted on the label of the medication bottle and per physician's order. Doses dispensed

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230824102537

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/30/2023

NARRATIVE

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are documented on a Medication Administration Record. Based on information received on today's visit, there is insufficient evidence to conclusively determine if the medications were not properly managed.

Based on the interviews conducted and medications reviewed, the above allegations are unsubstantiated.

No deficiencies were cited on this visit.

Exit interview was conducted and a copy of the report was given.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC9099 (FAS) - (06/04)

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