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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850111
Report Date: 02/24/2022
Date Signed: 02/24/2022 06:42:30 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/15/2022 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20220215170600
FACILITY NAME:LEXINGTON ASSISTED LIVINGFACILITY NUMBER:
565850111
ADMINISTRATOR:SANJUANA ENRIQUEZFACILITY TYPE:
740
ADDRESS:5440 RALSTON STTELEPHONE:
(805) 644-6710
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:125CENSUS: 75DATE:
02/24/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Matteo DigrigoliTIME COMPLETED:
06:41 PM
ALLEGATION(S):
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Facility did not report an outbreak of COVID-19
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced complaint investigation visit. LPA met with Matteo Digrigoli Operations Manager who is authorized to review and sign reports.

During today's visit LPA toured the facility with Operations Manager, interviewed random staff and obtained copies of pertinent documents. Concerns were that the facility did not report a COVID outbreak of residents. During facility tour with Operations Manager at 10:50 am LPA observed resident #1 (R1)'s bedroom door with a note indicating that the resident is on isolation. Administrator stated that the resident was COVID positive and is on isolation. LPA asked Operations Manager if any other residents were COVID positive and Operations Manager stated that they did have approximately 14 other COVID positive residents recently however, they are off isolation now. Operations Manager stated that they did notify Public Health and residents responsible persons or family members. Interviews with random staff starting at 10:58 am

Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20220215170600
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LEXINGTON ASSISTED LIVING
FACILITY NUMBER: 565850111
VISIT DATE: 02/24/2022
NARRATIVE
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revealed that they were given a list of COVID positive residents approximately 2 to 2 1/2 weeks ago. Documentation received during facility visit at 11:28 am revealed that 19 residents were COVID positive from 2/4/22 to 2/16/22. LPA spoke with Deborah Leonard from Ventura County Public Health on 2/24/22 starting at 2:25 pm who stated that the licensee did not report to them the COVID positive residents from 2/4/22 to 2/16/22. Community Care Licensing did not receive any notification from the licensee regarding the COVID positive residents from 2/4/22 to 2/16/22. Based on the information obtained during the course of the investigation the allegation is deemed substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D):

Exit interview was conducted, today's report was reviewed and emailed to the Operations Manager.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220215170600
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEXINGTON ASSISTED LIVING
FACILITY NUMBER: 565850111
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2022
Section Cited
CCR
87211(a)(2)
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87211 Reporting Requirements(a)(2) Occurrences, such as epidemic outbreaks, poisonings…which threaten the welfare, safety or health of residents, personnel…shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
This requirement is not met as evidenced by
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Administrator stated that they will review and comply with regulation 87211(a)(2) and will provide documentation of training to CCL by 3//7/22.
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Based on interviews and record review, the licensee did not comply with the section cited above as the licensee did not report COVID positive residents to Community Care Licensing and Ventura County Public Health which poses a potential health and personal rights risk to persons 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3