197607575-7-12-2022-29-AS-SWAR-CG9SJW-20220712135550

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607575
Report Date: 07/12/2022
Date Signed: 07/12/2022 01:56:43 PM

Document Has Been Signed on 07/12/2022 01:56 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
CCLD Regional Office, 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: 3	DATE:	07/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Mariana Romano, Administrator		TIME COMPLETED:	02:00 PM

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Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Mariana Romano at 11:59 a.m., and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside, with Administrator Mariana Romano at 12:04 p.m., to ensure there are no health and safety hazards.

BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting.
RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars. The LPA observed sufficient amounts of soap, paper products in each restroom. The LPA advised the Administrators to ensure all restrooms display hand-washing signs. Between 12:12 p.m. and 12:23 p.m., hot water temperatures measured between 105.4 and 110.4 degrees Fahrenheit in the common and private restrooms.
KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 113.6 degrees Fahrenheit at 12:32 p.m. At 12:34 p.m., the LPA observed two (2) medications in the facility refrigerator unsecured/unlocked; and accessible to residents in care. The Administrator secured both medications at the time of observation.
COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed required postings in the hallway. One (1) fire extinguisher was observed to be fully charged with a service date of 04/19/22.

Continue on LIC809C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

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: 07/12/2022

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BACKYARD/ FRONTYARD: The backyard, and front yard has a covered outdoor area equipped with furniture for resident use. There was one (1) body of water noted, which was locked and secured.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The Infection Control plan has not yet been submitted, and the Administrator will submit to CCL. This facility has records of staff and resident vaccinations. The facility can designate a single-person room to isolate persons if there is a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies, and procedures as it pertains to infection control.

The following deficiency was observed (See LIC 809-D.), and cited from the California Code of Regulations, Title 22. Exit interview conducted. A copy of the report and appeal rights were provided via Email.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/12/2022 01:56 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
CCLD Regional Office, 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: 07/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above as there were two (2) medications accessible in the kitchen refrigerator which poses an immediate health, and safety risk to persons in care.
	POC Due Date: 07/12/2022
	Plan of Correction
1 2 3 4	Medications were locked/secured during the visit. POC met.

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: Salia Walker	TELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

LIC809 (FAS) - (06/04)

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