Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609515
Report Date: 02/07/2019
Date Signed 02/07/2019 05:25:50 PM


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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/30/2019 and conducted by Evaluator Mita Amin
COMPLAINT CONTROL NUMBER: 31-AS-20190130095502
FACILITY NAME:TOLUCA LAKE MANOR SENIOR ASSISTED LIVINGII LLCFACILITY NUMBER:
197609515
ADMINISTRATOR:ROMANO, MARIANAFACILITY TYPE:
740
ADDRESS:5133 HAZELTINE AVETELEPHONE:
(818) 426-9403
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91423
CAPACITY:6CENSUS: 6DATE:
02/07/2019
UNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Mariana RomanoTIME COMPLETED:
01:58 PM
ALLEGATION(S):
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Staff failed to keep the facility free from pest infestation
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Mita Amin met with Mariana Romano, Administrator for a complaint investigation regarding above allegation. Initial interview conducted at 9:30 am.

During the course of the investigation, LPA conducted a tour of the physical plant at 10:20 am. Interviews with resident and facility staff conducted during the tour. At 10:30 am LPA obtained facility documentation pertinent to the allegation and reviewed.

Information obtained during this investigation revealed that about 2 weeks ago night caregiver observed a cockroach in the kitchen at night. On or around 1/30/19, family member of resident#1(R1) showed bed bug in container to the administrator that he/she stated was found in R1's room. Ms. Romano contacted their pest control company. On 1/24/19, the service was provided and follow up inspection was conducted on 1/28/19 by Ecoshield Pest control.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Mita AminTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2019
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 31-AS-20190130095502
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TOLUCA LAKE MANOR SENIOR ASSISTED LIVINGII LLC
FACILITY NUMBER: 197609515
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2019
Section Cited
CCR
87303(a)
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Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
Based interviews conducted,
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Administrator provided copies of Service Report, provided by Ecoshield Pest control. and the contract. Administrator also have replaced the carpet for the hard wood floor since than. Administrator agreed to submit the final inspection report from the pest control company by 2/14/19.
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caregiver observed a cockroach in the kitchen at night and family member of resident#1(R1) showed bed bug in container that he/she stated was found in R1's room.
This poses a potential health and safety risk to the residents in care.
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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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Mita AminTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2019
LIC9099 (FAS) - (06/04)
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Control Number 31-AS-20190130095502
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TOLUCA LAKE MANOR SENIOR ASSISTED LIVINGII LLC
FACILITY NUMBER: 197609515
VISIT DATE: 02/07/2019
NARRATIVE
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According to Ms. Romano facility never had a problem or infestation with roaches or bed bugs. She do not recall any complain about bed bug from any other residents or their family. Interview indicates that exterminator comes every three month for routine service to insure facility is clear of insects/pest. LPA reviewed and obtained copies of the Service Report, provided by Ecoshield Pest control.

Interview with hospice nurse, who visits the facility twice a week to provide services to R1, have not observed any sign of insects or bed bug in the room or sign of bug bites on R1's body. Interview with alert resident#2(R2), reveals no issue with bugs or any kind of insects in the room.

No roaches or bed bugs observed during this visit. However there was an evidence that cockroach was observed one time at night by caregiver and bed bug may have found in room#3. Administrator reported this on incident report to inform CCL department. Therefore an allegation "Staff failed to keep the facility free from pest infestation" is substantiated at this time.

Appeal Rights/Exit Interview Conducted.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Mita AminTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2019
LIC9099 (FAS) - (06/04)
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