197609515-2-9-2022-29-AS-SURA-CBGLSD-20220209080030

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609515
Report Date: 02/08/2022
Date Signed: 02/09/2022 08:02:20 AM

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: 5	DATE:	02/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Mariana Romano		TIME COMPLETED:	05:30 PM

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

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection at 1:30 p.m. This annual inspection had an emphasis on infection control practices and procedures. LPA Urena met with Administrator Mariana Romano at 1:45 p.m., and explained the reason for the visit.

At 2:00 p.m., the LPA and Administrator 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.

KITCHEN: Kitchen appliances were found to be in operable condition. At 2:20 p.m., during the tour of the kitchen, the LPA, and Administrator observed that the facility’s supply of perishable fresh vegetables was found to be insufficient for five residents and three staff. The supply of fresh vegetables were observed today to be two tomatoes, three heads of lettuce, seven small potatoes, approximately five small onions, a butter squash, and an eggplant. The emergency non-perishable food for six residents, and three staff was found to be insufficient, additionally, many of the can and dry foods found in the emergency pantry were found have expiration dates ranging from 2018 to 2021. The LPA observed two fire extinguishers in the kitchen area to be fully charged and operational, last check date was April of 2021.

See LIC 809C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(a)(2)

Other Provisions

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the expired food(2018-2021) was observed in the emergency food pantry, which poses a potential health, and safety risk to persons in care.
	POC Due Date: 02/09/2022
	Plan of Correction
1 2 3 4	1. Submit proof (picture and grocery receipt) of additional food supply purchased to feed six residents and three staff to CCLD by 2/9/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022

LIC809 (FAS) - (06/04)

Page: 5 of 5

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(e)

87705 (e)Care of pesons with Dementia. Swimming pools and other bodies of water shall be fenced and in compliance with State and local building codes. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee didnot comply with the section cited above, as the LPA observed a large fountain in the front courtyard area, containing standin/running water, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/11/2022
	Plan of Correction
1 2 3 4	Licensee agreed to add rocks to the fountain to ensure water depth does not pose a hazard to residents in care. Licensee will send photos to the LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022

LIC809 (FAS) - (06/04)

Page: 2 of 5

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: 02/08/2022

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

BEDROOMS: There are five (5) bedrooms currently occupied as single occupancy. Bedrooms were supplied with sufficient bedding and linens, and there were no visible hazards.

BATHROOMS: There are five (5) bathrooms. Each bedroom has a bathroom. The bathrooms were found to have hand washing signs, personal grooming supplies, and paper towels.

COMMON AREAS: Common areas included the Living Room and Dining Room. All common areas were appropriately furnished to accommodate a maximum capacity of six (6) residents. There were no visible hazards.

SURROUNDING GROUNDS: The property is fenced. The LPA and administrator observed a large water fountain in the front courtyard area, containing standing/running water, not fenced, which poses an immediate health, safety or personal rights risk to persons in care. There is furniture appropriate for outdoor use and shade available for residents’ use.Based on observation, the licensee as

LPA Urena 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.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited, (Please refer to LICs 809-D).

Citations were issued today. Exit interview was conducted with Administrator. The report was reviewed with the Administrator, and signatures were obtained. A copy of the report and appeal rights were provided 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: 02/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022

LIC809 (FAS) - (06/04)

Page: 3 of 5