195850244-10-21-2024-29-AS-ABAN-DA9RCF-20241021125415

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850244
Report Date: 10/21/2024
Date Signed: 10/21/2024 12:55:11 PM

Document Has Been Signed on 10/21/2024 12:55 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CLARENDON SENIOR LIVING 2		FACILITY NUMBER:	195850244
ADMINISTRATOR/ DIRECTOR:	FERNANDEZ, JENNIFER		FACILITY TYPE:	740
ADDRESS:	5952 KENTLAND AVENUE		TELEPHONE:	(818) 274-1809
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY: 6		CENSUS: 4	DATE:	10/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:10 AM
MET WITH:	Jennifer Fernandez		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 10:10AM. LPA met with Administrator Jennifer Fernandez and reason for the visit was explained. Entrance interview conducted.

Beginning at 10:11AM, the LPA, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN/GARAGE: LPA inspected the kitchen at 10:11AM. Knives and sharps are stored in a locked drawer. Cleaning supplies and hazardous chemicals are inaccessible and locked under the sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. Food was stored at appropriate temperatures. At 10:13AM, LPA observed the locked garage. The garage can be accessed from the side of the property and from the dining area by the kitchen. The garage contains additional supplies, a washer and dryer, detergents, and an additional refrigerator/freezer with a lockbox for storing refrigerated medication.

BEDROOMS: The facility consists of seven (7) total bedrooms, six (6) are designated for single-resident use and one (1) is designated for staff use and is kept locked. Bedrooms #1, #3, #4, #5, and #6 have exits to the exterior. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, closet space, and sufficient lighting. At 10:16AM, LPA observed Resident #1 (R1) in Bedroom #6. File review revealed that R1 is bedridden, and that the facility has a fire clearance for bedridden residents only for Bedroom #1. Bedroom #6 is cleared for non-ambulatory. Administrator stated they are in contact with the fire department to get the bedridden fire clearance for Bedroom #6 and is also attempting to move R1 to Bedroom #1 in the meantime. Administrator stated that they have tried to relocate R1 to Bedroom #1 before, but the resident currently residing in Bedroom #1 is not willing to move. Administrator stated they will try to convince the resident. Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CLARENDON SENIOR LIVING 2	FACILITY NUMBER: 195850244
	VISIT DATE: 10/21/2024

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BATHROOMS: There are three (3) full bathrooms one in the main hallway and two Jack and Jill's (between room #4 and staff room, and room #5 and #6) designated for residents, staff, and visitors. The showers are equipped with nonskid mats. Grab bars were observed in the bathrooms. LPA measured water temperatures in all three (3) bathrooms to be between 108.3 – 114.8 degrees Fahrenheit between 10:19AM – 10:24AM, which is within the required range.

COMMON AREAS: This includes the living room, family room, and dining room. LPA observed common areas to be clean and properly furnished at the time of the visit. Facility is maintained at a comfortable temperature. The facility smoke alarm system is hard wired. The smoke detectors and two (2) fire doors were tested at 10:31AM and the carbon monoxide detector was tested at 10:32AM; all were operable at the time of the visit. There is one (1) fire extinguisher by the kitchen which was fully charged and last serviced on 08/28/2024. There is a functioning telephone on the premises. Emergency exiting plans/sketch, emergency telephone numbers, license, and personal rights are posted on the entry way wall. LPA observed auditory exit alarms by all exit doors in the common areas and bedrooms to be functional and operating.

OUTDOOR SPACE: The backyard has a covered patio area with furniture including a table and chairs. There were no bodies of water on the premises. Only one (1) pathway is used as an emergency exit which was free of obstruction and was equipped with a self-closing and self-latching door.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 08/24/2024.

MEDICATION REVIEW: Medications are centrally stored and locked in a cabinet in the dining room. LPA began medication review at 10:32AM and medications for two (2) residents were observed. All medications reviewed were stored and documented per regulation.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CLARENDON SENIOR LIVING 2	FACILITY NUMBER: 195850244
	VISIT DATE: 10/21/2024

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RECORD REVIEW: LPA began record review at 10:50AM. LPA reviewed four (4) out of four (4) resident files and three (3) out of five (5) personnel files for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Resident and personnel files were complete and had no missing documents.

INTERVIEWS: During today's visit, LPA interviewed two (2) staff and two (2) residents.

During today's visit, LPA obtained a copy of the facility's liability insurance.

Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Civil penalty was issued in the amount of $500. Administrator was informed that failure to correct deficiency may result in additional civil penalties.

Exit interview conducted, report issued, and appeal rights provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/21/2024 12:55 PM - It Cannot Be Edited

Created By: Angela Barutyan On 10/21/2024 at 12:32 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: CLARENDON SENIOR LIVING 2	FACILITY NUMBER: 195850244
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in that one (1) bedridden resident was residing in a bedroom without bedridden fire clearance room which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2024
	Plan of Correction
1 2 3 4	Administrator stated the licensee has contacted the fire department to get a new fire clearance and provided proof. Administrator stated they will also try to relocate the resident to bedroom #1 which has a bedridden fire clearance. Administrator will provide proof of the relocation or the fire department's response to CCL by 10/22/2024.

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:

Kristin Heffernan

LICENSING EVALUATOR NAME:

Angela Barutyan

LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

LIC809 (FAS) - (06/04)

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