<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850111
Report Date: 08/31/2022
Date Signed: 08/31/2022 12:05:20 PM


Document Has Been Signed on 08/31/2022 12:05 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:LEXINGTON ASSISTED LIVINGFACILITY NUMBER:
565850111
ADMINISTRATOR:ERIC TERRILLFACILITY TYPE:
740
ADDRESS:5440 RALSTON STTELEPHONE:
(805) 644-6710
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:125CENSUS: 73DATE:
08/31/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ashley VillarrealTIME COMPLETED:
12:04 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) JoAnn Rosales conducted a Case Management - Deficiencies visit at the facility. LPA met with staff Ashley Villarreal - Community Liaison Director who is authorized to review and sign reports.

A review of R1’s medication records conducted on 08/11/22 starting at 10:17 am revealed that R1 was not given their Escitalopram 5 mg tablets which were to be given daily at 8 am on 2/17/22, 2/18/22 and 2/19/22. Interviews conducted with staff on 2/24/22 starting at 11:07 am revealed that R1 was not given their Escitalopram 5 mg on 2/17/22, 2/18/22 and 2/19/22 as they did not have anymore and they were waiting on a refill.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

Exit interview was conducted. Today's reports and appeals rights were reviewed and emailed to the Administrator

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/31/2022 12:05 PM - It Cannot Be Edited

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: LEXINGTON ASSISTED LIVING
FACILITY NUMBER: 565850111

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2022
Section Cited

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care Services(a)(4) The licensee shall assist residents with self-administered medications as needed.


This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on interviews and medication review, the licensee did not comply with the section cited above as R1 did not get their medication as prescribed which poses an immediate health 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
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: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2