197609028-9-20-2023-29-AS-JOLN-CVV2CR-20230920171711

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609028
Report Date: 09/20/2023
Date Signed: 09/20/2023 05:17:30 PM

Document Has Been Signed on 09/20/2023 05:17 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:	09/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Jennifer Fernandez, Administrator		TIME COMPLETED:	05:30 PM

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Licensing Program Analyst (LPA) Jenny Olson arrived at the facility unannounced to conduct a required annual visit at 3:15 p.m. When LPA arrived, there were two staff and four residents present. LPA was greeted by backup Administrator and informed them of the reason for the visit.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives are stored in a locked drawer in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

Common areas: Living and dining room furniture were observed to be in good condition. At 4:30 p.m., carbon monoxide detector were tested and operational at the time of the visit. LPA observed required postings throughout the common space, yet the PUB 475 was not 20"x26".

The backyard has covered outdoor area equipped with furniture for client use. No bodies of water noted. The washer and dryer are in the garage. The garage is locked.

Restrooms: The three resident restrooms were clean and sanitary and in operating condition. The bathrooms were sufficiently stocked with soap and paper towels.

Bedrooms: There are six (6) resident rooms, which were furnished. A linen closet was located outside of the rooms, which stocked extra linens and towels.

Records: LPA reviewed staff records around 3:30 p.m. LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. Staff did not have current first aid/CPR certification verification in the facility but the owner has it and will send to LPA. Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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: 09/20/2023

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INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol could be improved. The facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

Due to time constraints LPA was unable to finish the annual and will return at another date to continue the annual inspection.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC809 (FAS) - (06/04)

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