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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850310
Report Date: 10/03/2024
Date Signed: 10/03/2024 12:39:54 PM

Document Has Been Signed on 10/03/2024 12:39 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 3FACILITY NUMBER:
195850310
ADMINISTRATOR/
DIRECTOR:		JENNIFER G. FERNANDEZFACILITY TYPE:
740
ADDRESS:5911 FARRALONE AVENUETELEPHONE:
(818) 357-0579
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 1DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:18 AM
MET WITH:Jennifer FernandezTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 9:18AM. LPA met with Administrator Jennifer Fernandez and reason for the visit was explained. Entrance interview conducted.

Beginning at 9:20AM, 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: LPA inspected the kitchen at 9:20AM. Knives and sharps are stored in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of 2 (two) days perishable and 7 (seven) days non-perishable food and an emergency water supply. Food was stored at appropriate temperatures. At 09:21AM, LPA observed three (3) tomatoes, two (2) peppers, two (2) packages of okra, and two (2) zucchini that were spoiled. Staff discarded all items immediately.

BEDROOMS: The facility consists of seven (7) total bedrooms, six (6) are designated for single-resident use and 1 (one) is designated for staff use and is kept locked. Bedroom #5 is temporarily utilized as a staff room for a maintenance worker for the past month. Administrator anticipates that Bedroom #5 will no longer be used as a staff room in the next 2-3 weeks. 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 09:34AM, LPA observed Resident #1 (R1) in Bedroom #3. R1 is bedridden and the facility has a fire clearance for bedridden residents only for Bedroom #1. Bedroom #3 is cleared for non-ambulatory. Bedroom #1 is currently empty. Administrator stated they will move R1 from Bedroom #3 to Bedroom #1 as it is cleared for bedridden.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 10/03/2024 12:39 PM - It Cannot Be Edited


Created By: Angela Barutyan On 10/03/2024 at 11:17 AM
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 3
FACILITY NUMBER: 195850310

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024

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
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Based on observation and record review, the licensee did not comply with the section cited above in that a bedridden resident is retained in a non-bedridden room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Administrator stated they will move the resident from bedroom #3 to bedroom #1, as bedroom #1 has a bedridden fire clearance. Administrator will submit photographic proof to CCL by 10/04/2024.
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that one staff member did not have a criminal record clearance transfer which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee associated staff during the visit. POC is cleared.
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: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/03/2024 12:39 PM - It Cannot Be Edited


Created By: Angela Barutyan On 10/03/2024 at 11:17 AM
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 3
FACILITY NUMBER: 195850310

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (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
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Based on observation, the licensee did not comply with the section cited above in that temperatures measured between 121.1 to 122.3 degrees F which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Administrator will record water temperature for 5 days and will submit water log to CCL by 10/17/2024.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that several perishable food items were not of good quality which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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Staff discarded all expired items immediately. POC is cleared.
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: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


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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 3
FACILITY NUMBER: 195850310
VISIT DATE: 10/03/2024
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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 guests. The showers are equipped with nonskid mats. Grab bars were observed in the bathrooms. LPA measured water temperatures in the all three (3) bathrooms to be between 119.2 – 125.4 degrees Fahrenheit between 09:27AM – 09:39AM. Administrator lowered the water temperature during the visit and provided water temperature logs. LPA remeasured water temperatures to be between 121.1 – 122.3 degrees Fahrenheit between 11:36AM – 11:44AM.

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 of 72 degrees Fahrenheit. The facility smoke alarm system is hard wired. The carbon monoxide detector in the hallway was tested at 09:32AM and the smoke detectors and three (3) fire doors were tested at 09:46AM; 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 which were 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.

GARAGE/LAUNDRY: At 09:44AM, LPA observed the locked garage. The garage can be accessed from the side of the property and from the dining area. The garage contains additional supplies, a washer and dryer, detergents, and an additional refrigerator/freezer with a lockbox for storing refrigerated medication.

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 08/14/2024.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
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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 3
FACILITY NUMBER: 195850310
VISIT DATE: 10/03/2024
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RECORD REVIEW: LPA began record review at 10:10AM. LPA reviewed one (1) out of one (1) resident files and three (3) out of six (6) 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. At 10:25AM, LPA observed Staff #1 (S1) without a criminal record clearance transfer. Administrator contacted the licensee, Joseph Jose, who immediately associated S1 to the facility. Administrator confirmed that S1 has been at the facility for one month and licensee confirmed to LPA telephonically that S1 was associated to the licensee’s other facilities.

MEDICATION REVIEW: Medications are centrally stored and locked in a cabinet in the dining room. LPA began medication review at 09:50AM and medications for one (1) resident was observed. All medications reviewed were stored and documented per regulation.

INTERVIEWS: During today's visit, LPA interviewed two (2) staff and attempted an interview with one (1) resident.

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

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalty was issued in the amount of $1000. Administrator was informed that failure to correct deficiencies 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: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
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