197609515-12-13-2021-29-AS-JAPL-C9P24T-20211213160429

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609515
Report Date: 12/13/2021
Date Signed: 12/13/2021 02:48:07 PM

Substantiated

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
09/21/2020 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20200921083222

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:	09:30 AM
MET WITH:	Mariana Romano		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff left resident in soiled diaper for extended period of time

INVESTIGATION FINDINGS:

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This is an amended report.

On 12/13/2021, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced subsequent complaint visit and met with the Administrator at 9:30 a.m. LPA Urena explained the reason for the visit. The reason of the visit was to issue an amended report which was originally issued on 08/05/2021.

Regarding the Allegation: It is alleged that staff left residents in soiled diapers for an extended period of time; that residents are not being changed during the night, and residents are left in wet diapers and dried excrement all night.

Substantiated

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-20200921083222

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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On 08/05/2021, LPA Urena interviewed staff #1 (S1) and staff #2 (S2) and asked about the diaper change schedule for residents. S1 covers the day shift and stated that the diapers are changed beginning at 7:30am and two hours thereafter throughout the day. S2 covers the evening shift and stated that diapers are changed at 7:30pm and at 11:00pm, before S2 goes to bed. As a result, residents do not receive diaper changes, if needed, between the hours of 11:00 p.m. and 7:30 a.m. Based on the interviews with staff and their answers, this allegation is found to be Substantiated at this time.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies are cited (Please refer to LIC 9099-D)

The Allegation’s finding issued on the 08/05/2021 Report, is being amended from Unsubstantiated to Substantiated.

Exit interview conducted. Today's reports, and appeal rights were reviewed with Administrator. 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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Control Number 29-AS-20200921083222

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/13/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 12/17/2021 Section Cited CCR 87625	1 2 3 4 5 6 7	87625- Incontinence Care-The licensee shall... accept or retain a resident who has a manageable ...incontinence condition: (b)The licensee shall be responsible for ...: (2) Ensuring that incontinent residents are checked, including during the night. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee agrees to set up a schedule to ensure sufficient incontinent checks during the night and a way to ensure that the incontinent care has been completed. Staff will need to fill out an incontinent care log. Deficiency was corrected on todays's date 12/13/2021.
	8 9 10 11 12 13 14	Based on interviews, the Licensee did not ensure residents are checked during the night for incontinence, which poses a health and safety, and personal risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 12/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021

LIC9099 (FAS) - (06/04)

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