197609515-1-30-2023-29-AS-SURA-CNKMJV-20230130083942

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609515
Report Date: 01/27/2023
Date Signed: 01/30/2023 08:39:50 AM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/30/2023 08:39 AM - It Cannot Be Edited

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:	01/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Mariana Romano		TIME COMPLETED:	12:22 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection at 10:00 a.m. This annual inspection had an emphasis on infection control practices and procedures. LPA Urena met with Administrator Mariana Romano at 10:05 a.m., and explained the reason for the visit.

At 10:15 a.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. The emergency non-perishable food for six residents, and three staff was found to be sufficient. The fresh food supply was found to be appropriate for the five residents currently residing at the facility. Kitchen knives are stored and locked in a kitchen drawer. The LPA observed two fire extinguishers in the kitchen area to be fully charged and operational.

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. Lighting and room temperature were found to be appropriate.

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.

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: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

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

LIC809 (FAS) - (06/04)

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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: 01/27/2023

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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 with running water, however the water fountain is filled with stones so that the water is leveled with the stones in the fountain. There is furniture appropriate for outdoor use, and shade available for residents’ use.

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.

Exit interview was conducted with Administrator. The report was reviewed with the Administrator, and signatures were obtained. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC809 (FAS) - (06/04)

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