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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609026
Report Date: 12/06/2022
Date Signed: 12/06/2022 01:31:25 PM


Document Has Been Signed on 12/06/2022 01:31 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 2FACILITY NUMBER:
197609026
ADMINISTRATOR:LEVI, JUSTINFACILITY TYPE:
740
ADDRESS:5952 KENTLAND AVETELEPHONE:
(818) 676-0144
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 5DATE:
12/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Joseph JoseTIME COMPLETED:
12:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a Case Management – Other visit, for the purposes of observing whether this location is ready for a pre-licensing inspection. Fire Inspector Linsay Pellegrini was also in attendance. The LPA and the Inspector met with the staff and explained the reason for the visit. Administrator Joseph Jose arrived at approximately 12:25 p.m.

During the physical plant tour, the following was noted:
- Smoke detectors continued to chirp
- At 11:23 a.m., it was noted that the exit sliding glass door leading out of Bedroom #1 was missing a handle
- At 11:25 a.m., it was noted that the door to Bedroom #2 is not closing properly. However at 12:37 p.m., it was closing properly.
- At 11:26 a.m., the staff room was observed to be unlocked. There were accessible medications in the staff room. Also, there was a latch on the staff door, which needs to be removed.
- An electrical wiring issue was identified, as when the smoke detectors are triggered, the fire door leading into the hallway to staff room, bedroom #2, bedroom #3, bedroom #4 is not closing.
- At 11:27 a.m., an armchair was placed in front of the hallway leading into Bedroom #5 and Bedroom #6
- At 11:28 a.m., the exit in Bedroom #5 was obstructed
- At 11:32 a.m., it was noted that the sliding glass door leading to the backyard was broken
- At 11:36 a.m., Comet cleanser was observed accessible in the common bathroom
- At 11:38 a.m., a leak was discovered in the shower/tub in the common hallway bathroom. However, it stopped leaking during the visit. In addition, the non-skid mat appeared unclean.
- At 11:42 a.m., it was observed that there was a makeshift room attached to the kitchen/dining room area. Staff claimed that it was a staff room. This is not identified on the facility sketch, nor is the identified room permitted as a bedroom
- At 11:50 a.m., the garage was observed to be unlocked. Chemicals were accessible in the garage.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022
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


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 2
FACILITY NUMBER: 197609026
VISIT DATE: 12/06/2022
NARRATIVE
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On 12/1/2022, Inspector Pellegrini inspected this location to conduct their fire clearance inspection. This was the second time that Inspector Pellegrini had been to this location. On 12/01/2022, Inspector Pellegrini observed and photographed that the exit slider door leading to the backyard was tied shut with a cord.

The following deficiencies were observed (See LIC 809-D.) and cited from the CA Code of Regulations, Title 22. Exit interview conducted. A copy of the report was issued, along with appeal rights.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/06/2022 01:31 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 2
FACILITY NUMBER: 197609026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/08/2022
Section Cited

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87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above, as there was a broken handle, a leak, doors not closing properly, an unclean mat in the bathroom, a broken sliding glass door, and chirping smoke detectors, with poses an immediate health and safety risk to residents in care.
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Type A
12/08/2022
Section Cited

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87307(d)(6) Personal Accommodations and Services. All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above, as an armchair was blocking a hallway and the exit in room #6 was obstructed, which poses an immediate personal rights risk to residents in care.
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2. Conduct an in-service training with staff, regarding the personal rights of residents and ensuring the staff understand compliance.
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 12/06/2022 01:31 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 2
FACILITY NUMBER: 197609026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2022
Section Cited

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87705(f)(2) Care of Persons with Dementia. Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above, as there were accessible medications in the unlocked staff room, and accessible chemicals in the garage and bathroom, which poses an immediate health and safety risk to residents in care.
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Type B
12/12/2022
Section Cited

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87307(a)(2)(B) Personal Accommodations and Services. No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building. This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above, as a staff/makeshift room is adjacent to the kitchen/dining area and is not identified on the facility sketch, 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4