197609515-10-27-2020-29-AS-JAPL-C892W8-20211028174503

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609515
Report Date: 10/27/2020
Date Signed: 10/27/2020 12:46:16 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
10/27/2020 and conducted by Evaluator Eva Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20201027074024

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:	10/27/2020
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Mariana Romano		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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9

Absence of Supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Eva Miller conducted an initial 10-day Complaint Visit at the facility in reference to the allegation listed above. LPA met with Administrator Mariana Romano.

The complainant alleges that there was an absence of supervision on this date at approximately 6:00am. Staff #1 (S-1), the sole staff on duty was providing care and supervision to 3 residents. S-1 developed a medical emergency resulting in Resident #1 (R-1) calling 911summoning Emergency Medical Services (EMS). EMS had S-1 transported via ambulance. At that time there were no other Staff on duty. R-1 attempted unsuccessfully to call the Administrator. Staff #2 (S-2) was scheduled to report for duty at 6:00am but did not arrive. Los Angeles Fire Department personnel contacted the Long Term Care Ombudsman and then remained at the facility until facility personnel arrived. LPA conducted an interview with the Administrator, a tour of the physical plant, interviews with 3 of 4 residents and a review of pertinent facility documents. Based on the information obtained the allegation is substantiated. Citation issued, civil penalties assessed due to a zero tolerance deficiency and copy of the report provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Eva Miller	TELEPHONE: (818) 326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

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-20201027074024

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: 10/27/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely Type A 10/27/2020 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by.	1 2 3 4 5 6 7	The Administrator agrees to provide CCL with a current, complete and correct Personnel Report (LIC 500) that documents sufficient staffing and includes designated on-call staff with contact information and estimated response time to the facility in an emergency. This deficiency resulted in an absence of
	8 9 10 11 12 13 14	Based on statements of admission from the Administrator there was an absence of supervision of residents in care by qualified staff on 10/27/20 between 6:00am and 7:00am (approximately) resulting in an immediate threat to the health and safety of residents in care.	8 9 10 11 12 13 14	supervision which is a zero tolerance deficiency as per Health & Safety Code 1597.58 which states that an immediate Civil Penalty of $500 will be assessed at the time of the citation and an additional $100 per day until the deficiency is corrected.
	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: Eva Miller	TELEPHONE: (818) 326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

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