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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609028
Report Date: 12/06/2022
Date Signed: 12/06/2022 02:06:10 PM


Document Has Been Signed on 12/06/2022 02:06 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 3FACILITY NUMBER:
197609028
ADMINISTRATOR:LEVI, JUSTINFACILITY TYPE:
740
ADDRESS:5911 FARRALONE AVETELEPHONE:
(818) 992-8313
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
12/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Joseph JoseTIME COMPLETED:
02:10 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 Administrator Joseph Jose and explained the reason for the visit.

During the physical plant tour, the following was observed:
  • Debris was obstructing the sliding glass door in Bedroom #3, Bedroom #4, and Bedroom #5
  • The latch on the sliding glass door leading to the backyard needs to be fixed, and the sliding door in Bedroom #4 does not open all of the way
  • At 1:35 p.m., one of the dining rooms chairs was observed to be broken
  • During a previous visit, Inspector Pellegrini identified a strong odor in Bedroom #6. Yet during today's visit, it was identified that the carpet was being replaced in Bedroom #6 and the smell in Bedroom #6 was not potent. It was communicated that the carpet and additional repairs shall be completed within the next seven (7) days, if not earlier.


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. Staff Jennifer Guevarra Fernandez was authorized to sign the report.
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)
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Document Has Been Signed on 12/06/2022 02:06 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: 12/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2022
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 the latch on the rear sliding glass needs repair, the sliding door in room #4 doesn't fully open, a broken dining chair, and there is debris in the sliding glass doors, 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)
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