197609515-2-25-2025-29-AS-ZCHN-DE97LL-20250225204543

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609515
Report Date: 02/25/2025
Date Signed: 02/25/2025 08:49:28 PM

Document Has Been Signed on 02/25/2025 08:49 PM - 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/ DIRECTOR:	ROMANO, MARIANA		FACILITY TYPE:	740
ADDRESS:	5133 HAZELTINE AVE		TELEPHONE:	(818) 808-0661
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91423
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	02/25/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Marina Romano		TIME VISIT/ INSPECTION COMPLETED:	05:45 PM

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Licensing Program Analyst (LPA) Zabel Chochian conduct a required annual vist today at this location.

LPA Urena was greeted by staff and the Administrator Mariana Romano. Introductions conducted and reason for the visit was explained.

At approximately 10:45 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.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 74 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The two (2) fire extinguishers were fully charged and were last serviced 01/27/2025. The LPA observed required postings throughout the common space. KITCHEN: Kitchen appliances were found to be in operable condition. The emergency non-perishable food for residents and staff was found to be sufficient. The fresh food supply was found to be appropriate for the residents currently residing at the facility. Kitchen knives are stored and locked in a kitchen drawer. BEDROOMS: There are six (6) residents’ 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. There was a linen closet in the hallway with extra towels and linens. There at total of seven (7) bedrooms. One bedroom is designated for staff. BATHROOMS: There are six (6) bathrooms. Each bedroom has a bathroom. The bathrooms were found to have personal grooming, hygiene and sanitary supplies. Hot water temperature measured within the regulation limits (112*f).

OUTDOOR AREA: The property is fenced. The LPA and Administrator observed a large water fountain in the front courtyard area with running water; the water fountain is filled with stones so that the water is leveled with the stones in the fountain. Patio furniture in the backyard; shaded area available for resident's comfort.

Desaree Perera	TELEPHONE: (818) 596-4347
Zabel Chochian	TELEPHONE: (818) 419-5440
	DATE: 02/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

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: 02/25/2025

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RECORDS: Records review began at 11:45 a.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All residents’ Appraisal and Needs and services plan was missing resident/responsible person signature. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training.

Last disaster drills conducted in 12/2024. First aid kit observed complete; first aid manual/guide included.

MEDICATIONS: Medications review began at 3p.m.; medications are centrally stored and locked in a cabinet in the kitchen; medications are labeled and checked for expiration dates. Following error observed during the medication review: No physician prescription orders for OTC medications and vitamins for two (2) out of four (4) residents medications reviewed. PRN authorization letter not on file for three (3) residents with PRN medications.

INFECTION CONTROL: The facility has 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.

Copy of the following documents were requested to be sent to CCLD:

- LIC500 Personnel Report/schedule
- Copy of the liability insurance renewal

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

Exit interview conducted; appeal rights discussed and copy of report provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

LIC809 (FAS) - (06/04)

Page: 2 of 9

Document Has Been Signed on 02/25/2025 08:49 PM - It Cannot Be Edited

Created By: Zabel Chochian On 02/25/2025 at 05:56 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(b)

(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above. No PRN authorization letter on file for three out five residents. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2025
	Plan of Correction
1 2 3 4	Administrator agreed to obtain copy of the PRN authorization letter for three out of five residents. Submit copy of the authorization letter as proof by POC 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:

Desaree Perera

TELEPHONE: (818) 596-4347

LICENSING EVALUATOR NAME:

Zabel Chochian

TELEPHONE: (818) 419-5440

LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

LIC809 (FAS) - (06/04)

Page: 3 of 9

Document Has Been Signed on 02/25/2025 08:49 PM - It Cannot Be Edited

Created By: Zabel Chochian On 02/25/2025 at 05:56 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(e)

Incidental Medical and Dental Care Services

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. Three out four resident medications reviewed observed with no phyisian orders. This poses/posed a potential health, and safety risk to persons in care.
	POC Due Date: 02/27/2025
	Plan of Correction
1 2 3 4	Administrator stated that she will obtained a physician orders for all OTC and vitamins and submit by POC date.

Type B

Section Cited

CCR

87458(c)(1)(A)

Medical Assessment

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. No TB results on file for resident. This poses/posed a potential health, and safety risk to persons in care.
	POC Due Date: 02/27/2025
	Plan of Correction
1 2 3 4	Administrator contacted resident 1's doctor's office for a copy of the TB results. Administrator agreed to obtain and submit proof of TB clearance for resident #1 by POC date.

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:

Desaree Perera

TELEPHONE: (818) 596-4347

LICENSING EVALUATOR NAME:

Zabel Chochian

TELEPHONE: (818) 419-5440

LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

LIC809 (FAS) - (06/04)

Page: 4 of 9