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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850310
Report Date: 02/13/2024
Date Signed: 02/13/2024 04:37:23 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/05/2024 and conducted by Evaluator Valeria Conway
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20240205164208
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
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Jennifer G FernandezTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff did not properly observed and respond to resident's change of condition
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek arrived unannounced to conduct an initial 10-day visit. At 9:57AM, the LPAs met with staff and waited for Administrator to arrive. At 10:07 when Administrator arrived, we explained the reason for the visit and complaint allegations.

At 10:15AM LPAs requested resident's folders, employee's schedule, and documents where change of condition is documented on resident’s records. Administrator was not able to produce any communication between outside companies nor most recent appraisals were not conducted. At 11:00AM, the LPAs along with Administrator conducted a brief physical plant tour. At 12:31PM, LPA Kelly Dulek had a telephonic conversation with the Licensee Joseph Jose and after that between 11:37AM and 12:15PM the LPAs conducted interviews with two (2) staff members and the Administrator/caregiver. 12:45PM, LPA Valeria Conway Attempeted to interview the only resident at the facility however such person was sleeping.

Report continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20240205164208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/13/2024
NARRATIVE
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After talking to staff and reviewing records LPAs got to the understanding that the staff is only communicating verbally about changes on the residents between them and to the Administrator. No written reports nor notations are being logged or recorded between outside companies and the facility.
For Resident #1 (R1) most recent needs and service appraisal was dated on 06/01/2021. Administrator stated that there was a change of condition by R1 being on and off hospice and home health service however no information nor paperwork was found in R1's folder. Resident #2 (R2) admitted to the facility prior to change of ownership file didn't have a service appraisal.Based on interviews and records reviewed, LPAs have determined there is sufficient evidence to substantiate the allegations of staff not properly observed and respond to resident's change of condition.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency is cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties.

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

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20240205164208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2024
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes... licensee shall ensure that such changes are documented...responsible person, if any.

This requirement is not met as evidenced by:
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Seminars and training for emaployees. Administratior will document changes among residents including need and service apraisal.
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Based on interview and record review, the licensee did not comply with the above cited section, as R1 had a change of condition, as they were off and on hospice and home health, and this was not documented in R1’s file which posed a potential health risk to persons 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/05/2024 and conducted by Evaluator Valeria Conway
COMPLAINT CONTROL NUMBER: 29-AS-20240205164208

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
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Jennifer G FernandezTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Insufficient staffing.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek arrived unannounced to conduct an initial 10-day visit. At 9:57AM, the LPAs met with staff and waited for Administrator to arrive. At 10:07 when Administrator arrived, we explained the reason for the visit and complaint allegations.

At 10:15AM LPAs requested resident's folders and employee's schedule. At 11:00AM, the LPAs along with Administrator conducted a brief physical plant tour. At 12:31PM, LPA Kelly Dulek had a telephonic conversation with the Licensee Joseph Jose and after that between 11:37AM and 12:15PM the LPAs conducted interviews with two (2) staff members and the Administrator/caregiver. 12:45PM, LPA Valeria Conway Attempeted to interview the only resident at the facility however such person was sleeping.


Report continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
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.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20240205164208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/13/2024
NARRATIVE
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The complaint alleges that there was Insufficient staffing to meet the needs of the residents in care. During today's visit there was one (1) caregiver staff present and on duty for 1 (one) resident in care. Staff schedule dated 02/05-02/11 indicates 1 (one) staff present and on duty 07:00AM-11:00PM. Administrator indicated this schedule remains the same for the current week and a different staff is on duty during the night shift. Review of personnel report dated 09/20/2023 indicates two (2) residents in care and two (2) staff on duty during working hours. Staff indicated they are able to meet resident needs and they respond timely at the residents request. LPAs attempted to interview resident, however the resident was sleeping.

Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation "insufficient staffing" is deemed UNSUBSTANTIATED at this time.


No citations issued related to this allegation. Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
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
LIC9099 (FAS) - (06/04)
Page: 5 of 5