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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850111
Report Date: 07/27/2023
Date Signed: 07/27/2023 10:22:23 AM

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
05/21/2021 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20210521142052
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: 82DATE:
07/27/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mayra Gutierrez-Business Office ManagerTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Resident is left sitting in a chair in a room all day.
Staff are not adequately proving care and supervision to residents.
Staff do not safeguard resident's personal items.
Resident is not dressed in their own clothing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 05/24/2021 by LPAs K. Dulek and M. Guzman Chavez and a subsequent visit was conducted on 03/01/2023 by LPA Arroyo. On today’s visit, LPA Arroyo met with the Business Office Manager, Mayra Gutierrez and the reason for the visit was explained. Entrance interview.

During the initial visit on 05/24/2021, LPAs Dulek and Guzman Chavez conducted interviews with the Operations and Marketing Director and Wellness Director at 1:26 p.m. LPAs conducted a physical plant tour at 1:49 p.m., a kitchen and dining area tour at 2:05 p.m., conducted resident interviews between 2:52 p.m. and 3:25 p.m., and obtained copies of documents pertinent to the investigation. On 03/01/2023, LPA Arroyo conducted interviews with six staff and five residents between 12:15 p.m. and 1:55 p.m. and conducted a record review at 2:05 p.m. and obtained a copy of the census, staff schedule, activity calendar, and obtained copies of pertinent documents relevant to the investigation. (Report Continued on LIC 9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
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 7
Control Number 29-AS-20210521142052
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: 07/27/2023
NARRATIVE
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(Report Continued from LIC 9099...)

It was alleged that residents are left sitting in a chair in a room all day and staff are not adequately providing care and supervision to residents. It was reported that residents are left sitting in their rooms all day every day and staff are in the hall on their phones. Information obtained revealed the facility has a monthly calendar with activities that is distributed to the residents to participate in. During the plant visit, the LPA observed an activity calendar posted outside of the dining room in the Memory Care unit. Additionally, residents are encouraged to participate in the activities every day. Interviews conducted with staff revealed that although they would like all residents to participate in the daily activities, the residents have the right to refuse to participate at any time. Additionally, staff stated residents are checked on at least every two hours or when their pendants go off. Interviews conducted with residents revealed that their bedroom door is usually left open throughout the day unless they request the door to be closed. Residents reported to LPA they preferred to stay in their bedrooms to watch television and stated staff walk around all day checking in on them between meals. Based on interviews conducted with staff and residents, the Department does not have sufficient evidence to support the allegations of “resident is left sitting in a chair in a room all day” and “staff are not adequately providing care and supervision to residents”. Therefore, these allegations are deemed Unsubstantiated at this time.

It was also alleged that staff do not safeguard residents’ personal items. It was reported that personal items were lost. Interviews conducted with staff revealed that residents’ family members have not reported any items missing. Additionally, residents have not reported missing items to the facility or staff as well. Interviews conducted with residents revealed that a flashlight had gone missing once but later appeared and stated they most likely had misplaced it while using it. Additionally, residents reported having no items gone missing while living at the facility and stated they had no concerns while living at the facility. Based on the information obtained and interviews conducted, the Department does not have sufficient evidence to support the allegation of, “staff do not safeguard resident’s personal items”. Therefore, the allegation is deemed Unsubstantiated at this time.

(Report Continued on LIC 9099C...)

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20210521142052
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: 07/27/2023
NARRATIVE
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(Report Continued from LIC 9099C...)

It was further alleged that residents are not dressed in their own clothing. It was reported that residents had clothing on that was not theirs. Interviews conducted with staff revealed the resident’s clothing is provided by the residents when they move in or by the resident’s family members. Additionally, staff stated the facility will contact the family if the resident does not have enough clothes to wear. Furthermore, staff added that they do not supply any type of clothing other than bibs that residents request while they are eating. During interviews, residents displayed no concerns with the clothing they wear at the facility. Based on interviews conducted with facility staff and residents, the Department does not have sufficient evidence to support the allegation of “residents are not dressed in their own clothing”. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
05/21/2021 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20210521142052

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: 82DATE:
07/27/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mayra Gutierrez - Business Office ManagerTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Resident has sustained multiple falls while in care.
Facility did not follow reporting requirements.
Facility has scabies.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 05/24/2021 by LPAs K. Dulek and M. Guzman Chavez and a subsequent visit was conducted on 03/01/2023 by LPA Arroyo. On today’s visit, LPA Arroyo met with Executive Director (ED), Sarjuana Enriquez and the reason for the visit was explained. Entrance interview.

During the initial visit on 05/24/2021, LPAs Dulek and Guzman Chavez conducted interviews with the Operations and Marketing Director and Wellness Director at 1:26 p.m. LPAs conducted a physical plant tour at 1:49 p.m., a kitchen and dining area tour at 2:05 p.m., conducted resident interviews between 2:52 p.m. and 3:25 p.m., and obtained copies of documents pertinent to the investigation. On 03/01/2023, LPA Arroyo conducted interviews with six staff and five residents between 12:15 p.m. and 1:55 p.m. and conducted a record review at 2:05 p.m. and obtained a copy of the census, staff schedule, activity calendar, and obtained copies of pertinent documents relevant to the investigation. (Report Continued on LIC 9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20210521142052
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: 07/27/2023
NARRATIVE
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(Report Continued from LIC 9099A...)

It was alleged that the resident has sustained multiple falls while in care. It was reported that Resident #1 (R1) had multiple falls, fractured their hip, and obtained bruises; however, the facility did not notify R1’s family of the recuring incidents. Information gathered during the course of the investigation revealed R1 was admitted to the facility on 08/31/2019. Review of documents revealed that R1’s Physician’s Report (LIC 602A) dated 08/08/2019, indicated R1 as ambulatory, able to transfer to and from bed, and used a walker to ambulate independently. Additionally, the LIC 602A noted R1’s capacity for self-care to be able to bathe, dress/groom, feed, and care for their own toileting needs. However, on an updated LIC 602A dated 12/17/2019, indicated R1’s primary diagnosis as fracture of left pubis and noting R1’s capacity for self-care changing to R1 now requiring a one (1) person assist to bath, dress/groom, and assist with toileting needs. However, the facility did not report any unusual incident /injury report (LIC 624) to Community Care Licensing Department (CCLD) or R1’s family between September 2019 and September 2020 pertaining to R1. Furthermore, interviews conducted with staff revealed the facility typically has one (1) to two (2) unwitnessed falls a week, yet record review indicated the facility as having only one (1) to two (2) unwitnessed falls a month. Based on all the information and records obtained and reviewed, the allegation of “resident has sustained multiple falls while in care” is deemed Substantiated at this time.

It was also alleged that the facility had scabies and the facility did not follow reporting requirements. It was reported that the facility has had several scabies outbreaks but had not reported to either residents’ family members or CCLD. Review of documents revealed the facility had a scabies outbreak in October 2020 where R1 along with nine (9) other residents and all memory care staff were treated. Interviews conducted with staff revealed the entire Memory Care unit had scabies and the facility had everyone treated. However, staff stated they do not know if it was reported as the Wellness Director (WD) at the time was in charge of reporting any type of infectious disease to both CCLD and Public Health. The incident reports were submitted to CCLD reporting the scabies outbreak following the treatment; however, the incident reports were not reported until February 2021. Additionally, record review revealed facility had reported R1 having an unwitnessed fall on 01/07/2021 which resulted in R1 getting a right hip fracture and consequently having hip surgery the following day on 01/15/2021. Furthermore, incident reports are required to be reported to CCLD within seven (7) days of the incident(s) as required by California Code of Regulations.

(Report Continued on LIC 9099C...)

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20210521142052
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: 07/27/2023
NARRATIVE
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(Report Continued from LIC 9099C...)

Based on the information obtained during the course of the investigation, the allegation of “facility had scabies” is deemed Substantiated at this time. Additionally, based on the information and documentation obtained and reviewed, the allegation that “facility did not follow reporting requirements” is 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). Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and report was issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20210521142052
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: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/27/2023
Section Cited
CCR
87468.2(a)(4)
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Residents shall have all of the following personal rights: To care, supervision, and services that meet their
individual needs and are delivered by staff… to meet their needs.

This requirement is not met as evidenced by:
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The Licensee has agreed to do an in-house training on Regulation 87468.2 and submit proof to CCL by 08/11/2023.
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Based on the investigation, the licensee did not comply with the section cited above, as R1 was not properly cared for and supervised as R1 was diagnosed with a fracture of left pubis and physical condition changed...
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... while living at the facility without explanation and/or reporting of physical/health changes, which poses an immediate personal rights risk to residents in care.
Type B
08/11/2023
Section Cited
CCR
87211(a)(1)(D)
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A written report shall be submitted to the licensing agency ... within seven days of the occurrence: Any incident which threatens the welfare, safety, or health of any resident.

This requirement is not met as evidenced by:
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The Licensee has agreed to review and submit a statement of understanding for Regulation 87211 and submit to CCL by 08/11/2023.
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Based on interviews and documents reviewed, the licensee did not comply with the section cited above, as the facility had a scabies outbreak in October 2020 and did not report it to CCLD until February 2021, which poses a potential health & safety risk to residents 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7