565850111-2-24-2022-29-AS-KHEN-CKBS6L-20221018133606

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850111
Report Date: 02/24/2022
Date Signed: 02/24/2022 06:30:48 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
02/26/2021 and conducted by Evaluator Joann Rosales

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210226132843

FACILITY NAME:	LEXINGTON ASSISTED LIVING		FACILITY NUMBER:	565850111
ADMINISTRATOR:	OLSON, KATHLEEN		FACILITY TYPE:	740
ADDRESS:	5440 RALSTON ST		TELEPHONE:	(805) 644-6710
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	125	CENSUS: 75	DATE:	02/24/2022
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Matteo DiGrigoli		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident # 1 (R1) sustained multiple fractures while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) JoAnn Rosales conducted a subsequent complaint visit to deliver final findings for the above allegation. The initial visit was conducted on 03/01/2021 by LPA JoAnn Rosales. During today’s visit, LPA met with Matteo DiGrigoli Operations Manager and explained the reason for the visit.

On 02/26/2021, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that Resident #1 (R1) sustained multiple fractures while in care at the facility, including a broken nose, compression fractures of L1 and L3, as well as 5 broken ribs. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Dennis Douglas.

On 03/01/2021, between 1:38pm and 2:11pm, LPA Rosales conducted the initial complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the

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: 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)

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Control Number 29-AS-20210226132843

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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complaint investigation was conducted telephonically with Facility Wellness Director, Lidia Padilla. During the visit, LPA conducted a tour of the facility and requested copies of pertinent documents relevant to the investigation. LPA noted further investigation would be conducted by Investigator Douglas.

Investigator Douglas conducted interviews with the Facility Wellness Director on 03/11/2021, 04/13/2021, and 06/04/2021; with staff on 04/14/2021 and 06/04/2021; and with R1’s representative on 05/04/2021. Additionally, Investigator Douglas obtained and reviewed copies of facility records, incident reports, and Community Memorial Hospital medical reports related to R1.

Information gathered reflected R1 was admitted to the facility on 03/01/2020. Per the Physician’s Report dated 02/14/2020, R1’s primary diagnosis was age related macular degeneration. The secondary diagnosis was listed as Osteoporosis. R1 was listed as having mild cognitive impairment, ambulatory, and able to independently transfer to and from bed.

During the course of the investigation, it was revealed that R1 fell at the facility on multiple occasions and sustained injuries as a result. On 08/11/2020, R1 reported to staff that R1 fell a few days prior. The fall was unwitnessed by staff. At the time of R1’s disclosure, staff assessed R1 and observed a bruise on right hip. R1 complained of pain when walking, however, R1 refused medical attention and was not taken to the hospital. R1 was still able to ambulate with assistance of walker. R1’s representative took R1 for X-rays on 08/14/2020, no fractures were noted. On 08/21/2020, R1 was discovered by staff on the floor of R1’s bathroom. R1 informed staff that R1 lost balance and did not complain of pain or discomfort. No injuries or bruises were observed;
Continued on 9099C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (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)

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Control Number 29-AS-20210226132843

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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therefore, R1 was not taken to the hospital. On 09/18/2020, R1’s representative took R1 to R1’s primary care physician for a routine visit. At that time, it was discovered that R1 had a fractured femur which was now healing. It was also reported that on 11/18/2020, at approximately 1:30 am, staff discovered R1 sitting in the stairwell of the facility. R1 was observed to have a bump on forehead and bleeding from nose. R1 advised staff R1 fell. It appeared that R1 attempted to walk the stairs with walker. R1 was taken to Community Memorial Hospital ER as a precaution and diagnosed with a nasal bone fracture.

On 11/30/2020, R1 was moved to the memory care unit on the first floor of the facility due to the incident in the stairwell. However, it was reported that R1 experienced several additional falls following being moved to memory care. On 02/10/2021, R1 was in the presence of staff who was standing next to R1 at the time of the fall. The staff explained they could not catch R1 in time. R1 was transported to Community Memorial Hospital ER. R1 sustained compression fractures of L1 and L3 as well as 5 broken rib bones due to the fall.

During the course of the investigation, Investigator Douglas was made aware of two additional unwitnessed falls by R1 which occurred on 04/15/2021 and 04/21/2021. On 04/15/2021, in the middle of the night, staff discovered R1 sitting on the floor next to bed. R1 did not sustain any injuries. On 04/21/2021, in the middle of the night, R1 was again discovered on the floor in R1’s bedroom. R1 sustained a bump on forehead and was taken to Community Memorial Hospital ER as a precaution.

Continued on 9099C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (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)

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Control Number 29-AS-20210226132843

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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Based on the information Investigator Douglas obtained through records review and interviews, the allegation “Neglect/Lack of Supervision - Resident #1 (R1) sustained multiple injuries at the facility” is deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today. The Operations Manager was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).

Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (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)

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Control Number 29-AS-20210226132843

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 A 02/25/2022 Section Cited HSC 1569.312(a)	1 2 3 4 5 6 7	1569.312 Basic services requirements (a) Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2 This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Operations Manager will submit plan to provide proper level of care and supervision to ensure resident needs are met to CCL by 2/25/22.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section cited above as they failed to provide adequate care and supervision to R1 which attributed to R1 sustaining multiple injuries due to falls, which posed an immediate health and safety 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: 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)

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