195850310-9-25-2023-29-AS-JOLN-CVZTND-20230925145235

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850310
Report Date: 09/25/2023
Date Signed: 09/25/2023 02:53:35 PM

Document Has Been Signed on 09/25/2023 02:53 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:	CLARENDON SENIOR LIVING 3		FACILITY NUMBER:	195850310
ADMINISTRATOR:	JENNIFER G. FERNANDEZ		FACILITY TYPE:	740
ADDRESS:	5911 FARRALONE AVENUE		TELEPHONE:	(818) 357-0579
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 4	DATE:	09/25/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Joseph Jose, Executive Director		TIME COMPLETED:	03:10 PM

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Licensing Program Analyst (LPA) Jenny Olson arrived at the facility announced at 10:00 a.m. to conduct a pre-licensing inspection. The LPA met with Joseph Jose, Executive Director. This is a change of ownership application from Clarendon Senior Living 3 197609028 to Clarendon Senior Living 3 195850310. The current capacity is for six (6) residents, the facility currently has four (4) residents. The fire clearance was granted on 06/15/2023; in which bedroom #1 was cleared for bedridden, and all other rooms, bedroom #2, #3, #4 #5 and #6 were cleared for non-ambulatory clients. There is one staff room. Applicant successfully completed Component II on 09/13/2023. Component III was waived as the applicant currently operates eleven (11) other Residential Care Facilities for the Elderly (RCFE)’s that are currently in good standing. Applicant has attended Component III in the past and is RCFE administrator certified.

At 10:30 a.m., the LPA toured the physical plant areas inside and outside with applicant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen knives are stored locked and inaccessible in the drawer next to the kitchen sink. The supply of perishable and nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional.

BEDROOMS: There are seven (7) bedrooms in the facility; the facility has six (6) bedrooms for resident use, and one (1) staff room. The staff room is kept locked. Lighting in the rooms appeared adequate. All resident rooms and one (1) staff room were set up with beds, nightstands, lamps, chests of drawers, chairs, and closet space.

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.

Continued on LIC809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CLARENDON SENIOR LIVING 3	FACILITY NUMBER: 195850310
	VISIT DATE: 09/25/2023

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Around 11:30am the hot water temperature in bathrooms measured around 122.5 degrees Fahrenheit. The Director adjusted the water heater temperature at the time of the visit. LPA tested water temperature around 2:20pm which registered at 117.6 degrees Fahrenheit.

COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. The facility smoke alarm system is hard wired; the smoke detectors and carbon monoxide detector were operable at the time of the visit. There is (1) fire extinguisher which was fully charged and last serviced on 09/20/2023. 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.

MEDICATIONS: Medications will be in a locked cabinet located in the facility dining room which is locked and inaccessible to residents in care. The first aid supplies were complete, including a first aid manual.

FILES: Resident and staff records are stored in a book shelf located in the facility dining room.

LAUNDRY: The laundry area is located in the attached garage which is locked and inaccessible to residents in care.

EXTERIOR: The exterior passageways were clean and clear of any obstructions. There is a umbrella in the backyard with a table and chairs for resident use. There are no bodies of water noted on the premises. The facility has an attached garage used for laundry and storage space. There are no other structures on the property.

INFECTION CONTROL: The facility has an adequate supply of PPE and the facility is able to obtain additional supplies as needed. The facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Continued on 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CLARENDON SENIOR LIVING 3	FACILITY NUMBER: 195850310
	VISIT DATE: 09/25/2023

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Facility is not compliance with Title 22 Regulations at this time. Applicant will be required to complete the following corrections and submit documentation to LPA Jenny Olson within 10 days:

- Copy of liability insurance.
- Verification of refrigerator and freezer at the correct temperature.

Upon receipt of the above items, physical plant will be in compliance with Title 22 regulations. This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new license number until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license.

Exit interview conducted, copy of report printed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC809 (FAS) - (06/04)

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