Clarendon Senior Living 3

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 11:34AM. LPA met with Administrator Jennifer Fernandez. Entrance interview conducted. Beginning at 11:37AM, the LPA, along with the Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: LPA inspected the kitchen at 11:37AM. Knives and sharps are stored in a locked drawer. At 11:38AM, LPA observed cleaning supplies and chemicals accessible under the sink. Administrator moved chemicals to the locked garage. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food and an emergency water supply. At 11:42AM, LPA observed an opened bottle of maple syrup and soy sauce stored in the pantry, however, bottles state to refrigerate after opening. Administrator discarded the items. BEDROOMS: The facility consists of seven (7) total bedrooms; six (6) are designated for single-resident use and one (1) is designated for staff use and is kept locked. Bedrooms #1, #3, #4, #5, and #6 have exits to the exterior. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, closet space, and sufficient lighting. BATHROOMS: There are three (3) full bathrooms; one (1) in the main hallway and two (2) Jack and Jill's (between room #4 and staff room, and room #5 and #6). LPA observed bathrooms to be clean, sanitary and in operating condition with grab bars and slip-resistant surfaces. Hot water temperatures were measured in bathrooms and were between 106.0-106.7 degrees F. Report Continued on LIC 809-C. COMMON AREAS: This includes the living room, family room, and dining room. LPA observed common areas to be clean and properly furnished at the time of the visit. The facility smoke alarm system is hard wired. The smoke detectors and carbon monoxide detector in the hallway were tested at 11:56AM; all were operable at the time of the visit. At 11:58AM, LPA observed the fire extinguisher by the kitchen last serviced over a year ago on 08/28/2024. Staff purchased and installed a new fire extinguisher during the visit on 09/11/2025. Emergency exiting plans/sketch, license, personal rights, and other required postings are posted on the entry way wall. LPA observed auditory exit alarms by all exit doors in the common areas and bedrooms. Staff replaced exit alarm batteries during the visit and alarms were functional. OUTDOOR SPACE: The backyard has a covered patio area with furniture including a table and chairs. There were no bodies of water on the premises. One (1) pathway is used as an emergency exit which was free of obstruction and equipped with a self-latching gate. LPA observed the door stopper by the exit gate preventing the door from closing; Administrator stated the door stopper will be repaired. GARAGE/LAUNDRY: At 12:00PM, LPA observed the locked garage. The garage can be accessed from the side of the property and from the dining area by the kitchen. The garage contains additional supplies, a washer and dryer, detergents, and an additional refrigerator/freezer. MEDICATION REVIEW: Medications are centrally stored and locked in a cabinet in the dining room. LPA began medication review at 12:05PM and medications for two (2) residents were observed. All medications were labeled and maintained in compliance with label instructions, and state and federal law. RECORD REVIEW: LPA began record review at 12:38PM. LPA reviewed three (3) out of three (3) resident files and four (4) personnel files for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Resident and personnel files were complete and had no missing documents. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill conducted on 09/11/2025 during the visit. During today's visit, LPA obtained a copy of the facility's liability insurance. No deficiencies cited at this time. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 11, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 9:18AM. LPA met with Administrator Jennifer Fernandez and reason for the visit was explained. Entrance interview conducted. Beginning at 9:20AM, the LPA, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: LPA inspected the kitchen at 9:20AM. Knives and sharps are stored in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of 2 (two) days perishable and 7 (seven) days non-perishable food and an emergency water supply. Food was stored at appropriate temperatures. At 09:21AM, LPA observed three (3) tomatoes, two (2) peppers, two (2) packages of okra, and two (2) zucchini that were spoiled. Staff discarded all items immediately. BEDROOMS: The facility consists of seven (7) total bedrooms, six (6) are designated for single-resident use and 1 (one) is designated for staff use and is kept locked. Bedroom #5 is temporarily utilized as a staff room for a maintenance worker for the past month. Administrator anticipates that Bedroom #5 will no longer be used as a staff room in the next 2-3 weeks. Bedrooms #1, #3, #4, #5, and #6 have exits to the exterior. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, closet space, and sufficient lighting. At 09:34AM, LPA observed Resident #1 (R1) in Bedroom #3. R1 is bedridden and the facility has a fire clearance for bedridden residents only for Bedroom #1. Bedroom #3 is cleared for non-ambulatory. Bedroom #1 is currently empty. Administrator stated they will move R1 from Bedroom #3 to Bedroom #1 as it is cleared for bedridden. Report Continued on LIC 809-C BATHROOMS: There are three (3) full bathrooms one in the main hallway and two Jack and Jill's (between room #4 and staff room, and room #5 and #6) designated for, residents, staff and guests. The showers are equipped with nonskid mats. Grab bars were observed in the bathrooms. LPA measured water temperatures in the all three (3) bathrooms to be between 119.2 – 125.4 degrees Fahrenheit between 09:27AM – 09:39AM. Administrator lowered the water temperature during the visit and provided water temperature logs. LPA remeasured water temperatures to be between 121.1 – 122.3 degrees Fahrenheit between 11:36AM – 11:44AM. COMMON AREAS: This includes the living room, family room, and dining room. LPA observed common areas to be clean and properly furnished at the time of the visit. Facility is maintained at a comfortable temperature of 72 degrees Fahrenheit. The facility smoke alarm system is hard wired. The carbon monoxide detector in the hallway was tested at 09:32AM and the smoke detectors and three (3) fire doors were tested at 09:46AM; all were operable at the time of the visit. There is one (1) fire extinguisher by the kitchen which was fully charged and last serviced on 08/28/2024. There is a functioning telephone on the premises. Emergency exiting plans/sketch, emergency telephone numbers, license, and personal rights are posted on the entry way wall. LPA observed auditory exit alarms by all exit doors in the common areas and bedrooms which were functional and operating. OUTDOOR SPACE: The backyard has a covered patio area with furniture including a table and chairs. There were no bodies of water on the premises. Only one (1) pathway is used as an emergency exit which was free of obstruction and was equipped with a self-closing and self-latching door. GARAGE/LAUNDRY: At 09:44AM, LPA observed the locked garage. The garage can be accessed from the side of the property and from the dining area. The garage contains additional supplies, a washer and dryer, detergents, and an additional refrigerator/freezer with a lockbox for storing refrigerated medication. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 08/14/2024. Report Continued on LIC 809-C RECORD REVIEW: LPA began record review at 10:10AM. LPA reviewed one (1) out of one (1) resident files and three (3) out of six (6) personnel files for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Resident and personnel files were complete and had no missing documents. At 10:25AM, LPA observed Staff #1 (S1) without a criminal record clearance transfer. Administrator contacted the licensee, Joseph Jose, who immediately associated S1 to the facility. Administrator confirmed that S1 has been at the facility for one month and licensee confirmed to LPA telephonically that S1 was associated to the licensee’s other facilities. MEDICATION REVIEW: Medications are centrally stored and locked in a cabinet in the dining room. LPA began medication review at 09:50AM and medications for one (1) resident was observed. All medications reviewed were stored and documented per regulation. INTERVIEWS: During today's visit, LPA interviewed two (2) staff and attempted an interview with one (1) resident. During today's visit, LPA obtained a copy of the facility's liability insurance. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalty was issued in the amount of $1000. Administrator was informed that failure to correct deficiencies may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 3, 2024

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff did not properly observed and respond to resident's change of condition

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek arrived unannounced to conduct an initial 10-day visit. At 9:57AM, the LPAs met with staff and waited for Administrator to arrive. At 10:07 when Administrator arrived, we explained the reason for the visit and complaint allegations. At 10:15AM LPAs requested resident's folders, employee's schedule, and documents where change of condition is documented on resident’s records. Administrator was not able to produce any communication between outside companies nor most recent appraisals were not conducted. At 11:00AM, the LPAs along with Administrator conducted a brief physical plant tour. At 12:31PM, LPA Kelly Dulek had a telephonic conversation with the Licensee Joseph Jose and after that between 11:37AM and 12:15PM the LPAs conducted interviews with two (2) staff members and the Administrator/caregiver. 12:45PM, LPA Valeria Conway Attempeted to interview the only resident at the facility however such person was sleeping. Report continued on LIC9099C Substantiated After talking to staff and reviewing records LPAs got to the understanding that the staff is only communicating verbally about changes on the residents between them and to the Administrator. No written reports nor notations are being logged or recorded between outside companies and the facility. For Resident #1 (R1) most recent needs and service appraisal was dated on 06/01/2021. Administrator stated that there was a change of condition by R1 being on and off hospice and home health service however no information nor paperwork was found in R1's folder. Resident #2 (R2) admitted to the facility prior to change of ownership file didn't have a service appraisal.Based on interviews and records reviewed, LPAs have determined there is sufficient evidence to substantiate the allegations of staff not properly observed and respond to resident's change of condition. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency is cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided. The complaint alleges that there was Insufficient staffing to meet the needs of the residents in care. During today's visit there was one (1) caregiver staff present and on duty for 1 (one) resident in care. Staff schedule dated 02/05-02/11 indicates 1 (one) staff present and on duty 07:00AM-11:00PM. Administrator indicated this schedule remains the same for the current week and a different staff is on duty during the night shift. Review of personnel report dated 09/20/2023 indicates two (2) residents in care and two (2) staff on duty during working hours. Staff indicated they are able to meet resident needs and they respond timely at the residents request. LPAs attempted to interview resident, however the resident was sleeping. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation "insufficient staffing" is deemed UNSUBSTANTIATED at this time. No citations issued related to this allegation. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 13, 2024 · control 29-AS-20240205164208

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Feb 28, 2024

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes... licensee shall ensure that such changes are documented...responsible person, if any. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as R1 had a change of condition, as they were off and on hospice and home health, and this was not documented in R1’s file which posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Feb 13, 2024

Plan of correction: Seminars and training for emaployees. Administratior will document changes among residents including need and service apraisal.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway conducted an unannounced Case Management visit to address deficiencies observed during an unrelated visit at the facility today. LPAs met with Administrator Jennifer Fernandez. Entrance interview conducted. During today's visit, LPAs interviewed Administrator beginning at 10:07AM and at various times throughout today's visit, toured the facility beginning at 11:00AM, spoke with the Licensee over the phone at 11:31AM, and LPAs reviewed resident files. During facility tour, the LPAs observed Staff #1 (S1) residing in the facility. Interview with Licensee revealed that S1 has been employed and residing in the facility since October or November 2023. However, review of Guardian showed S1 does not have a fingerprint background clearance. S1 indicated they had not completed their fingerprints as of today's date. Additionally, interview with Administrator revealed that there had been 2 other residents at the facility. Both Resident #1 (R1) and Resident #2 (R2) were on hospice and had passed away on 12/23/2023 and 01/14/2024, respectively. Review of documents sent to the Woodland Hills Adult and Senior Care Regional Office (RO) revealed that no death reports, incident reports, nor hospice notifications have been received at the RO since the facility opened. Interview with Administrator confirmed she did not send such reports to the RO. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies are cited (refer to LIC 809-D.) Civil penalty issued in the amount of $500. Administrator was informed that failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 13, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.17(c)(1)(A) · Plan of correction due date: Feb 13, 2024

(c) (1) (A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption...prior to employment, residence, or initial presence in a facility...scan results This requirement is not met as evidenced by: Based on observation, record review, and interview, S1 has been employed and residing in the facility since at least November 2023 and did not obtain a criminal record clearance, which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2024

Plan of correction: S1 was removed from the facility during today's visit. S1 will be taken to complete their fingerprinting. Licensee and Administrator understand S1 cannot be present in the facility until criminal record clearance is obtained.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Feb 28, 2024

87211 Reporting Requirements (a) (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurence of any of the events specified...disposition of the case. This requirement is not met as evidenced by: Based on interview and record review, R1 passed away on 12/23/2023 and R2 passed away on 01/14/2024 and written reports were not received nor sent to the Regional Office, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2024

Plan of correction: Administrator agreed to submit reports for both R1 and R2 to the Regional Office by POC due date. Additionally, Administrator will complete vendorized training on Reporting Requirements, including hospice notifications and submit proof of completed training by POC due date.