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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609026
Report Date: 12/16/2022
Date Signed: 12/16/2022 11:46:26 AM


Document Has Been Signed on 12/16/2022 11:46 AM - 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:
12/16/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Jennifer Guevarra Fernandez TIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a Plan of Correction visit, for the purposes of observing whether the corrections were made from the 12/06/2022 visit. The LPA met with Jennifer Guevarra Fernandez and explained the reason for the visit.

During the physical plant tour, the LPA observed the following:
  • One smoke detector is still chirping. However, Administrator Justin Levi sent confirmation that new smoke detectors were purchased 12/13/2022. Staff Fernandez indicated that they came within the last wee to fix them. Smoke detectors registering as operable but there is still an electrical issue.
  • The handle on the exit sliding glass door leading out of Bedroom #1 was replaced
  • The door to Bedroom #2 closed properly
  • No chemicals or medications accessible during the visit. Photos of locked medications and chemicals were sent to CCL prior to this visit.
  • Staff room was locked. The latch on the staff door was removed.
  • There were no obstructions or hazards observed during the visit.
  • Sliding glass door leading to the backyard was in operable condition at the time of the visit
  • No leak observed in the bathroom
  • The makeshift room attached to the kitchen/dining room was cleared out. It was refurnished as a seating area for staff, residents, and visitors.
  • Garage door was locked.
  • Additional Statement of Understanding/Plan of Action obtained during today's visit.



No additional citations issued, as the smoke detector issue appears to be an ongoing issue that requires further attention. Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
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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