197609515-8-6-2021-29-AS-SURA-C5MRR5-20210806131430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609515
Report Date: 08/06/2021
Date Signed: 08/06/2021 01:28:31 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 II LLC		FACILITY NUMBER:	197609515
ADMINISTRATOR:	ROMANO, MARIANA		FACILITY TYPE:	740
ADDRESS:	5133 HAZELTINE AVE		TELEPHONE:	(818) 808-0661
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91423
CAPACITY:	6	CENSUS: 3	DATE:	08/06/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Mariana Romano		TIME COMPLETED:	01:30 PM

NARRATIVE

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On 08/06/2021 at 11:00 am, Licensing Program Analyst (LPA) Sandra Urena arrived to facility, introduced herself and explained the reason for the visit. LPA conducted an unannounced required annual inspection visit.

INFECTION CONTROL: Upon entry, the facility has a sign in book and sanitizing gel. Infection Control signs were visible at entrance.

At 11:15 am 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.

Bedrooms: At 11:45am, LPA observed the Residents’ bedrooms. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Mattresses had plastic mattress covers.

Bathrooms: At 11:50 am, LPA observed the Residents’ restrooms. Restrooms were clean, shower area was in clean condition with grab bars and non-skid mat available. Paper towels were available for drying hands. Hand washing sign was displayed.

Kitchen: At 12:00 pm, LPA observed the kitchen/dining area. Knives are stored in a locked cabinet drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Emergency food supply is adequate for six residents and two staff.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021

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 II LLC	FACILITY NUMBER: 197609515
	VISIT DATE: 08/06/2021

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Outdoor Space: At 12:10 pm, LPA observed the Outdoor space. A shaded patio is available for residents to visit with family members. Side gate is unlocked.

Facility Records: At 12:30 pm LPA reviewed staff and residents’ records. All flies are in good order, and meet

requirements.

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. 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’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were cited at this time. Exit interview conducted. Signatures obtained. A copy of report was issued

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021

LIC809 (FAS) - (06/04)

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