197609515-2-23-2026-29-AS-ZCHN-DRKTGZ-20260223134400

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609515
Report Date: 02/13/2026
Date Signed: 02/23/2026 01:45:37 PM

Document Has Been Signed on 02/23/2026 01:45 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		CENSUS: 6	DATE:	02/13/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Mariana Romano		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

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

LPA Chochian was greeted by the Licensee/Administrator Mariana Romano. Introductions conducted and reason for the visit was stated.

At approximately 10a.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 75 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 12/06/2025. 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 two-day perishable and seven-day non-perishable food supply was found to be sufficient for the current census of the facility. Kitchen knives observed stored and locked in a kitchen drawer. BEDROOMS: There are total of seven (7) bedrooms. One bedroom is designated for staff. 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 is a linen closet in the hallway with extra towels and linens. 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 over the regulation limits at 10:36am, 12:50pm and 3:20pm (131.9*f - 136*f) in rooms #4, #5, #6. (Continue to LIC809c)

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 02/13/2026

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

RECORDS: Records review began at approximately 11 a.m. Residents’ records were reviewed for, but not limited to care plans, physician record, admission agreement, personal rights and consent forms. At approximately 12:30p.m. personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Records maintained current with required documents.

Last disaster drills conducted on 12/03/2025. First aid kit observed complete; first aid manual/guide included.

MEDICATIONS: Medications review began at 1:15p.m.; medications are centrally stored and locked in a cabinet in the kitchen; medications are labeled and checked for expiration dates. LPA reviewed five (5) residents medication and medication records. Medication procedures are followed accordingly. Minor technical documentation error noted with the start date recorded on the centrally stored medication record; start date was preset by pharmacy however medication was sent later in the evening. Staff corrected the start date to reflect correct date medication was punch out of the bubble pack.

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.

Discussion held with Licensee/Administrator to ensure submission of required documents: (Copy of the following documents were requested to be sent to CCLD:

- LIC500 Personnel Report/schedule
- Copy of the liability insurance renewal
- Infection Control and Emergency and Disaster Plan

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited, (refer to LICs 809-D). Exit interview conducted; appeal rights discussed and copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/23/2026 01:45 PM - It Cannot Be Edited

Created By: Zabel Chochian On 02/13/2026 at 03:47 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: 02/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Hot water temperature check conducted in rooms 4, 5, and 6 was noted at 131.9f-136.8f. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/17/2026
	Plan of Correction
1 2 3 4	Licensee/Administrator had staff adjust the hot water temperature immediately from the water heater that supplys to room 4,5, and 6. Licensee/Administrtor agreed to have staff monitor hot water temperature for rooms/bathrooms identified over required temperature. test the water temperature daily 3 times a day for 3 days and record temperature. Ensure hot water temperature is within 105-120. Submit log by 2/17/2026.

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.

	Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:

	Zabel Chochian
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026

LIC809 (FAS) - (06/04)

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