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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609028
Report Date: 12/16/2022
Date Signed: 12/16/2022 09:41:00 AM


Document Has Been Signed on 12/16/2022 09:41 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 3FACILITY NUMBER:
197609028
ADMINISTRATOR:LEVI, JUSTINFACILITY TYPE:
740
ADDRESS:5911 FARRALONE AVETELEPHONE:
(818) 992-8313
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
12/16/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Jennifer Guevarra FernandezTIME COMPLETED:
09:45 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:
  • Debris that was obstructing the sliding glass door in Bedroom #3, Bedroom #4, and Bedroom #5 was clear at the time of the visit. The sliding glass doors in the identified rooms open without issue.
  • The latch on the sliding glass door leading to the backyard was fixed. It was operational and the door opened without issue. The sliding door in Bedroom #4 opened without issue during today's visit.
  • Dining rooms chairs that were previously broken were in functional use at the time of the visit.
  • The flooring was replaced in Bedroom #6 and the LPA did not identify any odors in this room.


Plan of Correction met at this time. No additional citations issued. 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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