197609515-8-6-2021-29-AS-JAPL-C893CE-20211028180748

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609515
Report Date: 08/06/2021
Date Signed: 08/06/2021 01:26:47 PM

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
10/19/2020 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20201019113014

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:	ZIP CODE:	91423
CAPACITY:	6	CENSUS: 3	DATE:	08/06/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Mariana Romano		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff failed to keep facility free of pests

Staff failed to provide appropriate care and supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced subsequent complaint investigation regarding the above allegations. LPA me with the Administrator at 9:00am, and explained the reason for the visit.

It is alleged that the facility failed to keep facility free of pests. RP states that R1 collects recyclables, and garbage that R1 brings into the residential facility. RP states that the actions of R1, has resulted in vermin running in and out of the garage and into the alley. Additionally, RP states that RP witness bedbugs in the facility. LPA conducted a detailed tour of the facility rooms and beds to look for signs of bedbug infestation, and none was found. Every mattress in each of the six bedrooms has a plastic mattress cover. LPA was vigilant to look for vermin droppings and none was found.

Based on the physical observation of the facility bedrooms, beds, and garage, this allegation is deemed UNSUBSTANTIATED at this time.

Unsubstantiated

Estimated Days of Completion:

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.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20201019113014

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

NARRATIVE

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Regarding the allegation: Staff failed to provide appropriate care and supervision

It is alleged that the facility failed to provide care and supervision for R1 who wanders in the mornings at 5:30 am in inappropriate attire, collecting garbage and recyclable materials daily and especially on Wednesdays, which is trash day. After reviewing R1 file, LPA noted that R1 had the habit to wake up in the early mornings, and collect recyclable materials the day before trash day. Administrator provided pictures of the recyclable materials collected by R1, which piled up on the patio. Per R1 file, R1 was mobile and able to leave facility as needed. R1 last day at facility was June 30, 2021.

Based on the review of R1 file and interview with Administrator and staff, this allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted/ No citations issued/ 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

LIC9099 (FAS) - (06/04)

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