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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850310
Report Date: 02/13/2024
Date Signed: 02/13/2024 04:50:54 PM


Document Has Been Signed on 02/13/2024 04:50 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 3FACILITY NUMBER:
195850310
ADMINISTRATOR:JENNIFER G. FERNANDEZFACILITY TYPE:
740
ADDRESS:5911 FARRALONE AVENUETELEPHONE:
(818) 357-0579
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 1DATE:
02/13/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Jennifer FernandezTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway conducted an unannounced Case Management visit to address deficiencies observed during an unrelated visit at the facility today. LPAs met with Administrator Jennifer Fernandez. Entrance interview conducted.

During today's visit, LPAs interviewed Administrator beginning at 10:07AM and at various times throughout today's visit, toured the facility beginning at 11:00AM, spoke with the Licensee over the phone at 11:31AM, and LPAs reviewed resident files. During facility tour, the LPAs observed Staff #1 (S1) residing in the facility. Interview with Licensee revealed that S1 has been employed and residing in the facility since October or November 2023. However, review of Guardian showed S1 does not have a fingerprint background clearance. S1 indicated they had not completed their fingerprints as of today's date. Additionally, interview with Administrator revealed that there had been 2 other residents at the facility. Both Resident #1 (R1) and Resident #2 (R2) were on hospice and had passed away on 12/23/2023 and 01/14/2024, respectively. Review of documents sent to the Woodland Hills Adult and Senior Care Regional Office (RO) revealed that no death reports, incident reports, nor hospice notifications have been received at the RO since the facility opened. Interview with Administrator confirmed she did not send such reports to the RO.

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

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
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 2


Document Has Been Signed on 02/13/2024 04:50 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/13/2024
Section Cited
HSC
1569.17(c)(1)(A)

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(c) (1) (A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption...prior to employment, residence, or initial presence in a facility...scan results
This requirement is not met as evidenced by:
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S1 was removed from the facility during today's visit. S1 will be taken to complete their fingerprinting. Licensee and Administrator understand S1 cannot be present in the facility until criminal record clearance is obtained.
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Based on observation, record review, and interview, S1 has been employed and residing in the facility since at least November 2023 and did not obtain a criminal record clearance, which poses an immediate safety risk to residents in care.
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Type B
02/28/2024
Section Cited
CCR87211(a)(1)

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87211 Reporting Requirements (a)
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurence of any of the events specified...disposition of the case.
This requirement is not met as evidenced by:
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Administrator agreed to submit reports for both R1 and R2 to the Regional Office by POC due date. Additionally, Administrator will complete vendorized training on Reporting Requirements, including hospice notifications and submit proof of completed training by POC due date.
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Based on interview and record review, R1 passed away on 12/23/2023 and R2 passed away on 01/14/2024 and written reports were not received nor sent to the Regional Office, which poses a potential health and safety risk to residents in care.
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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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2