197609026-9-20-2022-29-AS-ECAS-CJFQPV-20220920122122

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609026
Report Date: 09/20/2022
Date Signed: 09/20/2022 12:22:01 PM

Document Has Been Signed on 09/20/2022 12:22 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 2		FACILITY NUMBER:	197609026
ADMINISTRATOR:	LEVI, JUSTIN		FACILITY TYPE:	740
ADDRESS:	5952 KENTLAND AVE		TELEPHONE:	(818) 676-0144
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 4	DATE:	09/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Rodrigo Guinto		TIME COMPLETED:	12:30 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) Elsie Campos arrived unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices. The LPA initially met with staff, whom contacted the Administrator. Administrator Representative Joseph Oyewole arrived shortly thereafter, and the LPA explained the reason for the visit. The LPA, along with staff, toured the facility to ensure there were no immediate health and safety hazards. The LPA spoke with residents during the tour; residents appeared well kept and no concerns were communicated. KITCHEN: Knives and chemicals are locked inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: There are seven rooms total; six private resident rooms and one designated staff room. Bedrooms had appropriate furniture, clean linens and sufficient lighting. Rooms were clean and clear of obstructions. RESTROOMS: The three restrooms were clean and sanitary with grab bars and non-skid surfaces. Between 10:55 a.m. and 10:57 a.m., water temperature measured between 113.5 and 117.6 degrees F. Restrooms were stocked with soap and paper towels. COMMON SPACES: The facility maintained a temperature of 75 degrees. Medications were kept locked in a cabinet located in the back wall of the dining room, which also had additional supplies. Smoke detectors and carbon monoxide detectors were operable. Living room and dining furniture were observed in good condition. Fire extinguisher was serviced December 2021. The backyard and exterior area of the facility had furniture area for resident use, however the area was not covered or kept in clean condition. The exterior of the facility was observed to have old furniture and items such as doors, glass that needed to be thrown away. In addition, the exterior windows were observed to have broken and or missing screen doors. The LPA observed spider webs throughout the exterior windows. No bodies of water noted. The garage is attached, is kept locked and was equipped with a laundry room, cleaning supplies and large supply of incontinent supplies. Additional food was observed in the garage in good condition.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

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 2	FACILITY NUMBER: 197609026
	VISIT DATE: 09/20/2022

NARRATIVE

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INFECTION CONTROL: Upon entry, there is a central entry point for screening and temperature checks. The facility’s cleaning protocol is sufficient. There is record of staff and resident vaccinations. The facility can designate a room to isolate persons if there is a confirmed case of COVID-19. Staff are up to date regarding guidelines around visitation and vaccine requirements. The facility has submitted an up-to-date Infection Control Plan. Staff have recently been trained on COVID-19 protocol and the monkey-pox epidemic. The policies and procedures pertaining to infection control were adequate.

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/20/2022 12:22 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: 09/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the window screens were observed to be in disrepair which poses a potential health and safety risk to persons in care.
	POC Due Date: 10/07/2022
	Plan of Correction
1 2 3 4	The Licensee agreed to the following: 1. Clean all out door windows to be free and clear of spider webs. 2. Replace broken screens and notify CCL no later than 10/7/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC809 (FAS) - (06/04)

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