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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609028
Report Date: 06/17/2020
Date Signed: 06/17/2020 01:17:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117
FACILITY NAME:CLARENDON SENIOR LIVING 3FACILITY NUMBER:
197609028
ADMINISTRATOR:LEVI, JUSTINFACILITY TYPE:
740
ADDRESS:5911 FARRALONE AVETELEPHONE:
(818) 992-8313
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
06/17/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Philip PantelicTIME COMPLETED:
11:34 PM
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Licensing Program Analyst (LPA) Aja Richardson conducted an unannounced case management visit to further investigate an incident that was received in the Woodland Hills Regional Office on 05/28/2020. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted telephonically with the facility administrator Philip Pantelic at 10:15 am.

According to the incident report it was reported that staff #1 hit resident #1 (R1) with a pillow. LPA conducted interviews with the Administrator on 6/2/2020 and 6/17/2020. According to the administrator the staff in question was not working during that night of the incident. LPA conducted additional interviews with R1 and R1's relative on 6/17/2020 between 9 am and 10 am. On 6/17/2020, LPA also viewed a video sent by facility Administrator showing R1 screaming "please stop hurting me" however there was no one in the room. When interviewed R1 stated the staff are very nice and never abusive. R1's relative also stated the staff are very nice and R1 often has behavioral episodes and they have had to take away R1's phone as R1 constantly calls the police. Facility staff is working with a psychiatrist, primary doctor, and R1's family regarding these episodes. At this time no further investigation will be done.

Exit Interview Closed. Report Emailed.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja RichardsonTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2020
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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