565850111-3-15-2023-29-AS-JAPL-CQ7RMJ-20230323130850

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850111
Report Date: 03/15/2023
Date Signed: 03/15/2023 03:57:19 PM

Unsubstantiated

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
05/09/2022 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20220509152612

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: 76	DATE:	03/15/2023
		UNANNOUNCED	TIME BEGAN:	09:42 AM
MET WITH:	Sanjuana Enriquez		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Facility staff failed to keep resident safe

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Teresa Camara and Esther Cortez conducted a subsequent complaint visit. LPAs initially met with Community Liaison Director Ashley Villarreal at 9:42 a.m. and later met with Executive Director Sanjuana "Joanna" Enriquez at 11:55 a.m. and explained the reason for the visit to both.

On 05/09/2022, the Department received a complaint alleging the facility staff failed to keep resident 1 (R1) safe. Specifically the complaint alleged that R1 was assaulted on the elevator by resident 2 (R2) on or about 4/5/2022. Resident 3 (R3) was also on the elevator during the incident.

(continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

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-20220509152612

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: 03/15/2023

NARRATIVE

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On 5/17/2022, LPA Camara conducted an initial complaint investigation visit. During the visit LPA interviewed staff at 2:58 p.m., reviewed and obtained pertinent records at 3:27 p.m., and interviewed three residents at 3:38 p.m., 3:45 p.m., and 4:31 p.m.

During today's visit on 3/15/2023, LPAs interviewed two staff at 2:39 p.m. and 2:44 p.m. and three residents at 10:04 a.m., 10:16 a.m. and 11:08 a.m.

Facility records showed the incident on 4/5/2022 at 11:40 a.m. with R1 was reported to the Department. The incident report stated R1 reported to staff they lost their balance and fell in the elevator. R1 hit their head and had a skin tear. Staff immediately called 9-1-1. R1 was released back to the facility the same day at approximately 4:30 p.m.

Staff who were interviewed stated that while R2 can sometimes get upset with people, they never witnessed R2 try and physically touch, push, hit or kick any other residents. R3 who as in the elevator during the incident could not recall how R1 fell. R2 denied doing anything other than yell for staff to come help as R1 had fallen in the elevator blocking the door. Other residents interviewed stated they have not witnessed R2 or any other resident be physically aggressive toward other residents.

Based on the information obtained during interviews and document reviews, the Department does not have sufficient evidence to support the above allegation. Therefore, the allegation "Facility staff failed to keep resident safe" is deemed unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided to Executive Director Sanjuana "Joanna" Enriquez.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

LIC9099 (FAS) - (06/04)

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