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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850111
Report Date: 11/18/2021
Date Signed: 11/18/2021 05:32:54 PM

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 LIVINGFACILITY NUMBER:
565850111
ADMINISTRATOR:SANJUANA ENRIQUEZFACILITY TYPE:
740
ADDRESS:5440 RALSTON STTELEPHONE:
(805) 644-6710
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:125CENSUS: 70DATE:
11/18/2021
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Matteo Digrigoli - Operations ManagerTIME COMPLETED:
05:31 PM
ALLEGATION(S):
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Untrained staff handing out medications
Facility does not have an Activities Director
Facilities internet is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a subsequent unannounced complaint investigation visit. LPA met with Operations Manager Matteo Digrigoli who is authorized to review and sign reports.

During today's visit LPA toured the facility and interviewed random residents and staff. Concerns were that staff #1 (S1) has not had medication training and assisted residents with their medications. Interviews on 10/14/21 starting at 2:39 pm and 11/18/21 starting at 2:06 pm with staff and residents revealed that S1 assisted residents with medications. Interview with S1 on 10/14/21 at 4:45 pm revealed that on 10/9/21 they assisted residents with their medications. S1 stated that they have no documentation of their medication training and they have not completed their medication training. Concerns were that the facility did not have an Activities Director. Interviews on 10/14/21 starting at 2:39 pm and 11/18/21 starting at 2:06 pm with staff and residents revealed that the facility did not have an Activities Director for approximately a month or more.
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: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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 5
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: 11/18/2021
NARRATIVE
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Concerns were that the facility internet was in disrepair as their was no wifi in areas of the facility. Interviews on 10/14/21 starting at 2:39 pm and 11/18/21 starting at 2:06 pm with staff and residents revealed that the internet did not work at times. Interview with the Operations Manager on 10/14/21 starting at 4:45 pm revealed that the internet was kind of spotty. Operations Manager stated that the control boxes that feed the internet cables to the ports were messed up. Operations Manager stated that the part took 45 days to get. Operations Manager stated that they were not aware that it was completely out. Operations stated that the internet issues have been resolved. A review of the receptionists notebook on 10/14/21 starting at 4:19 pm revealed that on 9/15/21 at 12:50 the phone and the internet were out.

Based on the information obtained during the course of the investigation the allegations are deemed substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were 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: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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: 11/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/23/2021
Section Cited
HSC
1569.69(a)(1)
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1569.69 Employees assisting residents with self-administration of medication; training requirements (a)(1) In facilities licensed to… This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self- administration of medications, and 8 hours…
This requirement is not met as evidenced by:
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Operations Manager stated that they will review and will comply with the regulation. Operations Manager stated that they will provide a letter indicating this to CCL by 11/23/21.
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Based on interviews, the licensee did not comply with the section cited above as S1 did not complete medication training prior to assisting residents with medications which poses a potential health risk to persons in care.
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Type B
11/23/2021
Section Cited
CCR
87219(f)
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87219 Planned Activities (f) Planned Activities. In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as…

This requirement is not met as evidenced by:
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Operations Manager stated that an Activity Director was hired on 11/1/21. Operations Manager stated that they will provide an updated LIC500 to include the new Activity Director to CCL by 11/23/21.
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Based on interviews, the licensee did not comply with the section cited above as the facility did not have an Activity Director which posed a potential 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: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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: 11/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/23/2021
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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Operations Manager stated that they will provide documentation of the repairs completed on their internet to CCL by 11/23/21.
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Based on interviews, the licensee did not comply with the section cited above as the facilities internet was not working properly which posed a potential 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: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5