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Department of
SOCIAL SERVICES
Community Care Licensing
COMPLAINT INVESTIGATION REPORT
Facility Number:
197609515
Report Date:
08/05/2021
Date Signed:
12/16/2021 11:03:38 AM
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
10/29/2020
and conducted by Evaluator
Sandra Urena
COMPLAINT CONTROL NUMBER:
29-AS-20201029182646
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:
08/05/2021
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Mariana Romano
TIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Failure to arrange for or provide transportation.
Failure to manage resident cash resources.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This is an amended report. Please refer to report issued on 12/13/2021.
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:
08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/05/2021
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-20201029182646
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:
08/05/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
SUPERVISOR'S NAME:
Jeralyn Ann Pfannenstiel
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Sandra Urena
TELEPHONE:
747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE:
08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/05/2021
LIC9099
(FAS) - (06/04)
Page:
2
of
2