565850111-5-28-2021-29-AS-DPEA-C79UVA-20210927155446

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850111
Report Date: 05/28/2021
Date Signed: 05/28/2021 01:41:17 PM

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
05/24/2021 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20210524103826

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: 75	DATE:	05/28/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lidia Padilla Wellness Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility staff shut-off water supply for a prolonged period of time

Facility staff did not provide advance notice of water shut-off to residents

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Brian Balisi and Martha Guzman-Chavez initiated a complaint investigation for the above allegations. LPAs met with Lidia Padilla and explained the reason for the visit.

Between 9:30am - 2pm, LPAs conducted a physical plant with Padilla, interviewed staff, residents and reviewed and obtained copies of documents relevant to the investigation.

In regards to Faciltiy staff shut-off water supply for a prolonged period of time, during the investigation through interviews with residents and staff as well as a review of facilty documents, it was revealed that all water was shut off on May 20th, between 10pm - 4am due to repairs. Based on information gathered during this visit, the department has sufficient evidence to determine that facility staff shut-off water supply for a prolonged period of time. Therefore, the above allegation is SUBSTANTIATED at this time.
Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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-20210524103826

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: 05/28/2021

NARRATIVE

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Continued on 9099

In regards to the allegation that Facility staff did not provide advance notice of water shut-off to residents , during the investigation through interviews with residents and staff, it was revealed that staff was aware of water needing to be shut off a week in advance to May 20th, between 10pm - 4am. Most residents and some staff that were interviewed were unaware of receiving an advanced notice regarding the water getting shut-off on May 20th, between 10pm - 4am. Based on information gathered during this visit, the department has sufficient evidence to determine that facility staff did not provide advance notice of water shut-off to residents. Therefore, the above allegation is SUBSTANTIATED at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210524103826

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: 05/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/04/2021 Section Cited CCR 87307(d)(2)	1 2 3 4 5 6 7	87307(d)(2) Personal Accommodations and Services The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Staff agreed to review section 87307 (d)(2) with administrative and support staff and will provide LPAs via E-mail, with documentation that a meeting was held and regulation reviewed by end of business day June 4, 2021.
	8 9 10 11 12 13 14	Based on LPAs interviews with residents and staff, the facility failed to provide a safe and healthful environment, as water was not available from 10pm to 4am on May 20th, which poses as a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 06/04/2021 Section Cited CCR 87468(a)	1 2 3 4 5 6 7	87468 Personal Rights – (a)Residents in residential care facilities for the elderly shall have personal rights... as applicable to the facility. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Staff agreed to create a written guideline for notifying all residents of future disruptions and provide LPAs with documentation by end of business day June 4, 2021.
	8 9 10 11 12 13 14	Based on LPAs interviews with residents and staff, the facility failed to provide advanced notice to residents that water was going to be shut off on May 20th, between 10pm – 4am, which poses as potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC9099 (FAS) - (06/04)

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