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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607575
Report Date: 09/22/2022
Date Signed: 09/22/2022 02:11:43 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/18/2020 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20200918164508
FACILITY NAME:TOLUCA LAKE MANOR SENIOR ASSISTED LIVING LLCFACILITY NUMBER:
197607575
ADMINISTRATOR:MARIANA ROMANOFACILITY TYPE:
740
ADDRESS:4560 CARTWRIGHT AVE.TELEPHONE:
(818) 426-9403
CITY:TOLUCA LAKESTATE: CAZIP CODE:
91602
CAPACITY:6CENSUS: 4DATE:
09/22/2022
UNANNOUNCEDTIME BEGAN:
10:26 AM
MET WITH:Mariana RomanoTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff not providing adequate food service
Staff did not provide hygiene products for residents
Staff left resident in soiled diaper for extended period of time
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection at the facility today regarding the above allegations. When the LPA arrived there was one staff and four residents present. Administrator Mariana Romano arrived at the facility at 10:47 AM.

The investigation for this complaint began on 09/28/2020. On this date, the LPA conducted a virtual inspection with the Administrator beginning at 11:15 AM. During the inspection, the LPA observed the common areas and kitchen. The LPA observed the front entry which had a bottle of hand sanitizer, masks, thermometer, and sign in sheet. Ms. Romano also showed the LPA two more bottles of hand sanitizer in the home. In the kitchen the LPA observed the menu and food supply. The LPA also observed the two bathrooms which had several bottles of hand soap, paper towels, and hygiene items in the shower.

Report continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 29-AS-20200918164508
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/22/2022
NARRATIVE
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During today's inspection beginning at 10:32 AM the LPA began a physical plant tour in the kitchen. The LPA observed the food supply. The LPA observed including but not limited to, fresh chicken from the meat department, sausage, and sausage links, along with home made chicken soup, fresh fruit and vegetables, and a variety of juices in the refrigerator and the cabinet. In the freezer various frozen items were observed including frozen turkey sausage links, chicken pot pies, and frozen dinners. The LPA observed the two resident bathrooms to have hand soap, paper towels, with shampoo and body soaps. At the front door hand sanitizer was observed with central entry check in point. Between 10:42 AM and 11:15 AM, the LPA conducted interviews with Resident #1 (R1), Resident #2 (R2), and the family member of R2.

The allegation of 'Staff not providing adequate food service' alleges the residents are only given water to drink and are only given the same foods from Costco, lasagna, burritos, and chicken During today's visit and during the virtual inspection, the LPA observed a variety of fresh and frozen food. Interviews also revealed no concerns regarding the quality or variety of food being served. Based on the information obtained, the allegation of 'Staff not providing adequate food service' is deemed unsubstantiated at this time.

The allegation of 'Staff did not provide hygiene products for residents' alleges there was no hand soap or hand sanitizer for staff and resident use and there was only dish soap to wash their hands. During the virtual inspection and today's inspection, the LPA observed hand sanitizer by the front door, and hand soap in both bathrooms along with other hygiene items available. Based on observation, the allegation of 'Staff did not provide hygiene products for residents' is deemed unsubstantiated at this time.

The allegation of 'Staff left resident in soiled diaper for extended period of time' alleged residents are found in soiled diapers in the morning. The LPA interviewed the Administrator and she stated she is the current night staff and she checks the residents to see if they are wet every two to three hours. Interviews with residents and the family member revealed no issues or concerns regarding incontinence care received during the night. Based on the information obtained, the allegation of 'Staff left resident in soiled diaper for extended period of time' is deemed unsubstantiated at this time.

Exit interview and report reviewed with the Administrator. A copy of the report was emailed.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2