<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850310
Report Date: 09/11/2025
Date Signed: 09/11/2025 01:55:50 PM

Document Has Been Signed on 09/11/2025 01:55 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 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: 3DATE:
09/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:34 AM
MET WITH:Jennifer FernandezTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 11:34AM. LPA met with Administrator Jennifer Fernandez. Entrance interview conducted.

Beginning at 11:37AM, 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 11:37AM. Knives and sharps are stored in a locked drawer. At 11:38AM, LPA observed cleaning supplies and chemicals accessible under the sink. Administrator moved chemicals to the locked garage. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food and an emergency water supply. At 11:42AM, LPA observed an opened bottle of maple syrup and soy sauce stored in the pantry, however, bottles state to refrigerate after opening. Administrator discarded the items.

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.

BATHROOMS: There are three (3) full bathrooms; one (1) in the main hallway and two (2) Jack and Jill's (between room #4 and staff room, and room #5 and #6). LPA observed bathrooms to be clean, sanitary and in operating condition with grab bars and slip-resistant surfaces. Hot water temperatures were measured in bathrooms and were between 106.0-106.7 degrees F. Report Continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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)
Page: 2 of 4
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: 09/11/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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. The facility smoke alarm system is hard wired. The smoke detectors and carbon monoxide detector in the hallway were tested at 11:56AM; all were operable at the time of the visit. At 11:58AM, LPA observed the fire extinguisher by the kitchen last serviced over a year ago on 08/28/2024. Staff purchased and installed a new fire extinguisher during the visit on 09/11/2025. Emergency exiting plans/sketch, license, personal rights, and other required postings are posted on the entry way wall. LPA observed auditory exit alarms by all exit doors in the common areas and bedrooms. Staff replaced exit alarm batteries during the visit and alarms were functional.

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. One (1) pathway is used as an emergency exit which was free of obstruction and equipped with a self-latching gate. LPA observed the door stopper by the exit gate preventing the door from closing; Administrator stated the door stopper will be repaired.

GARAGE/LAUNDRY: At 12:00PM, 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.

MEDICATION REVIEW: Medications are centrally stored and locked in a cabinet in the dining room. LPA began medication review at 12:05PM and medications for two (2) residents were observed. All medications were labeled and maintained in compliance with label instructions, and state and federal law.

RECORD REVIEW: LPA began record review at 12:38PM. LPA reviewed three (3) out of three (3) resident files and four (4) 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.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: 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, with the last drill conducted on 09/11/2025 during the visit.

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

No deficiencies cited at this time. Exit interview conducted and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4