197609515-12-16-2021-29-AS-JAPL-C9SS23-20211217122848

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609515
Report Date: 12/13/2021
Date Signed: 12/16/2021 10:45:37 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: 4	DATE:	12/13/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Mariana Romano		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Failure to arrange for or provide transportation
Failure to manage resident cash resources

INVESTIGATION FINDINGS:

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This report has been amended due to formatting issues, there is no change in the findings.

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced subsequent complaint investigation regarding the above allegations. The LPA met with the Administrator at 10:30am and explained the reason for the visit.

On 08/05/2021 at 10:00 a.m., the LPA reviewed a copy of the admission agreement. On 08/05/2021 at 10:30 a.m., the LPA conducted interviews with the facility administrator. On 08/05/2021 at 11:30 a.m., the LPA conducted interviews with facility residents. On 08/05/2021 at 12:00 p. m., the LPA conducted interviews with facility staff.

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: 12/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021

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-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: 12/13/2021

NARRATIVE

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Regarding the allegation: Failure to arrange or provide transportation
It is alleged that the facility failed to arrange or provide transportation to appointments for residents.
In review of the specifications of the Admission Agreement, the monthly payment only covers the basic board and care services for residents. No other services are noted in the admission agreements for residents. As per regulations, the facility is only responsible for arranging for transportation, if not stated otherwise in the admission agreement.
Interviews with staff # 1 (S1), staff #2 (S2), and staff #3 (S3) revealed that residents are offered transportation services by staff; however, residents may accept or decline such transportation services. Additionally, transportation is offered to residents through the Mobile Physician Associates services. The administrator stated that they only refused to provide transportation on one occasion as the location exceeded the acceptable travel radius. Resident interviews confirmed that such transportation is offered; however, though they do not always accept those services. Therefore, based on the information gathered through interviews, and records review, the allegation is deemed to be UNSUBSTANTIATED at this time.

Regarding the allegation: Failure to manage resident cash resources.
It is alleged that the facility failed to manage residents’ cash resources; specifically, that the facility is not paying for resident #1’s (R1’s) phone bill. The LPA conducted records review, resident and staff interviews. According to the Admission Agreement, the facility is responsible for providing basic board and care services. On page #3 of the Admissions Agreement, it specifies that residents can ask for additional optional services: Incontinent Care Products, and Long-Distance Calls (as needed). Staff # (S3) was interviewed about the cash management for residents. S3 stated that the facility does not manage residents’ cash. LPA Eva Miller interviewed the administrator on 11/9/2020 and was informed that R1 has two cell phones with two different carriers. The administrator has taken R1 to pay for the bills, but in the past, there were occasions when R1 waited until the bill was overdue before letting the administrator know that it needed to be paid. However, the phone bill was not the responsibility of the facility.

Based on the information gathered through interviews, and records review, the allegation: Failure to manage resident cash resources; is deemed to be UNSUBSTANTIATED at this time.
Exit interview conducted with Administrator Mariana Romano. No citations issued. Report was issued via email.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021

LIC9099 (FAS) - (06/04)

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