565850111-4-12-2022-29-AS-KHEN-CGPVHJ-20220726162712

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850111
Report Date: 04/12/2022
Date Signed: 04/12/2022 11:34:03 AM

Substantiated

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
10/07/2021 and conducted by Evaluator Joann Rosales

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20211007102349

FACILITY NAME:	LEXINGTON ASSISTED LIVING		FACILITY NUMBER:	565850111
ADMINISTRATOR:	SANJUANA ENRIQUEZ		FACILITY TYPE:	740
ADDRESS:	5440 RALSTON ST		TELEPHONE:	(805) 644-6710
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	125	CENSUS: 68	DATE:	04/12/2022
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Sanjuana Enriquez		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Residents are not getting changed timely

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) JoAnn Rosales conducted a subsequent unannounced complaint investigation visit to deliver final investigation findings. LPA met with Administrator Sanjuana Enriquez.

Concerns were that residents were not getting changed timely. Interviews on 10/14/21 starting at 2:39 pm and 11/18/21 starting at 2:06 pm revealed that staff have gone into work and observed R1 really wet along with their sheets and residents have had to wait over 30 minutes at times for help. A review of the receptionist notebook on 10/15/21 starting at 4:33 pm revealed that on 7/16/21 resident #1 (R1) called 911 for help, 7/14/21 R1 called 911 again indicating that they are not getting help, 7/9/21 R2 called 3 times for help 6:49, 7:00 and 7:06 as they were not getting anyone to go to their room, 6/21/21 11:29 R3 called stating that it has been 50 minutes and they have not gotten any help. On 5/30/21 10 pm to 6 am caregiver noted that R4 was not changed for bed. On 5/24/21 10:48 pm it was noted by a caregiver that the evening caregiver did not

Continued on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20211007102349

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: 04/12/2022

NARRATIVE

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change R4 or get them ready for bed. 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 and appeals rights were reviewed and emailed to the Administrator

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20211007102349

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: 04/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/22/2022 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated that they will provide documentationof staff training regarding regulation 87464(f)(1) to CCL by 4/22/22.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above as residents were not being changed timely which poses a potential health and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

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