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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197609028
Report Date:
09/20/2022
Date Signed:
09/20/2022 04:30:53 PM
Document Has Been Signed on
09/20/2022 04:30 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 3
FACILITY NUMBER:
197609028
ADMINISTRATOR:
LEVI, JUSTIN
FACILITY TYPE:
740
ADDRESS:
5911 FARRALONE AVE
TELEPHONE:
(818) 992-8313
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:
02:00 PM
MET WITH:
Jennifer Fernandez
TIME COMPLETED:
04:45 PM
NARRATIVE
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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 were locked inaccessible. However, at 2:11 p.m. the LPA observed cleaning supplies and chemicals under the kitchen sink unlocked and accessible to residents in care. 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. Bedroom #6 had a strong odor of urine upon entry, which was confirmed by staff to be embedded in the carpet. Bedroom #5 had visible water damage to the wall, floors and ceiling from a leaking AC unit and is currently undergoing repairs. All other rooms were clean and clear of obstructions.
RESTROOMS
:
The three restrooms were clean and sanitary with grab bars and non-skid surfaces. Between 2:19 p.m. and 2:23 p.m., water temperature measured between 120.7 and 122.9 degrees F. Restrooms were stocked with soap and paper towels.
COMMON SPACES
:
The facility maintained a temperature of 75 degrees. Medications are kept in a cabinet located on the back wall of the dining room, which also had additional supplies however it was observed to be unlocked at the time of the visit. Staff confirmed that the lock on the medication cabinet is broken. Smoke detectors and carbon monoxide detectors were operable. Living room and dining furniture were observed in good condition. Fire extinguisher was serviced November 2021. The backyard and exterior area of the facility had a covered patio area with furniture for resident use. The exterior of the facility was observed to be undergoing cleaning efforts. 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 and PPE. 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 3
FACILITY NUMBER:
197609028
VISIT DATE:
09/20/2022
NARRATIVE
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INFECTION CONTROL
: Upon entry, the staff member whom answered the door was not wearing an appropriate face covering. In addition, the staff did not ask the LPA the screening questions nor did they take the LPA's temperature. This was brought to the staff’s attention, whom immediately put on the appropriate face mask.
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
7
Document Has Been Signed on
09/20/2022 04:30 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 3
FACILITY NUMBER:
197609028
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/20/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as upon LPA's entry into room #6 a strong odor of urine was immediatley noticed. Bedroom #5 was observed to have visible water damge to floor carpeting, wall and ceiling all of which pose an immediate health and safety risk to persons in care.
POC Due Date:
09/21/2022
Plan of Correction
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The administrator agreed to do the following:
1. Schedule a professional cleaning service or carpet replacement for bedroom #5 and 6 and notfiy CCL of scheduled appointment no later than 9/21/22. Cleaning and repiars must eliminate urine odors.
2. Repair water damage in room #5 walls, carepet and ceiling. Notify CCL of repairs no later than 10/14/2022.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as a medication cabinet in the dining room containing centrally stored medications were observed unlocked and accessible which poses an immediate health and safety risk to persons in care.
POC Due Date:
09/21/2022
Plan of Correction
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The administrator agreed to the following:
1. Immediatley secure centrally stored medications with an appropriate lock or relocate medications to an appropriatley locked cabinet. Submit proof to CCL no later than 9/21/2022.
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)
Page:
3
of
7
Document Has Been Signed on
09/20/2022 04:30 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 3
FACILITY NUMBER:
197609028
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/20/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) 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:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above as cleaning supplies and disinfectants under the kitchen sink were observed to be unlocked and accessible twhich poses an immediate health and safety risk to persons in care.
POC Due Date:
09/21/2022
Plan of Correction
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The administrator agreed to the following:
1. Immediatley secure all cleaning supplies and disinfectants with an appropriate lock or relocate supplies to an appropriatley locked storage area. Submit proof to CCL no later than 9/21/2022.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
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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)
Page:
4
of
7
Document Has Been Signed on
09/20/2022 04:30 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 3
FACILITY NUMBER:
197609028
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/20/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above, as staff were observed not wearing appropriate face coverings and did not ask COVID-19 screening questions upon the LPA's arrival, which poses a potential personal rights risk to persons in care.
POC Due Date:
09/23/2022
Plan of Correction
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The administrator has agreed to do the following:
1. Submit staff training sign in sheet and supporting documentation on Infection Control Practices PIN 21-38-ASC regarding mask wearing in the facility to LPA by 09/23/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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)
Page:
5
of
7
Document Has Been Signed on
09/20/2022 04:30 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 3
FACILITY NUMBER:
197609028
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/20/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above as bathroom water temperatures registered above 120 degrees fahrenheit which poses an immediate health and safety risk to persons in care.
POC Due Date:
09/21/2022
Plan of Correction
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The adminsitrator agreed to do the following:
1. Immediatley adjust the water temperatures to meet department regulations. Notify CCL no later than 9/21/2022.
2. Submit a 5 day log recording of all bathroom temperatures. Submit to CCL no later than 9/27/2022.
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)
Page:
7
of
7