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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850111
Report Date: 08/09/2023
Date Signed: 08/09/2023 04:55:30 PM


Document Has Been Signed on 08/09/2023 04:55 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
WOODLAND HILLS NORTH, 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: 83DATE:
08/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Ashley Villareal -Family AdvisorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced subsequent Case Management - Incident visit to the above facility. The purpose of the visit is to conclude an investigation initiated by LPA during a Case Management- Incident visit conducted on 07/20/2023. The LPA met with Family Advisor Ashley Villarreal and the reason for the visit was explained.

On 07/20/2023, the Department received an Unusual/Serious Incident Report (SIR) reflecting that on 7/20/2023, Resident #1 had eloped from the facility at approximately 1:00 p.m. It was reported that R1 was outside of a nearby I-Hop restaurant when the facility received a call from Housekeeping Staff (S1), who was off the clock and having lunch informing staff that R1 had eloped from the facility and was with them. Upon receiving the information, staff picked up and returned R1 back to the facility. Information gathered during the initial visit reflected that per R1’s Physicians Report (LIC602) dated 12/14/2018, R1 does not have a diagnosis of dementia and is able to leave the facility unassisted, with their next of kin being notified. However, based on interviews conducted staff voiced concerns regarding R1 leaving the facility unassisted and being unable to find R1’s way back to the facility. A review of R1’s nursing notes reflected that changes in condition were not being documented. Interviews conducted and documents reviewed reflected that even though staff observed R1 to have a change in condition, facility staff did not documented in R1’s reappraisal, or notify R1s Primary Care Physician (PCP) of these concerns.

Report will continue on LIC809-C
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LEXINGTON ASSISTED LIVING
FACILITY NUMBER: 565850111
VISIT DATE: 08/09/2023
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On 08/02/2023, the Department received a second SIR. It was reported that on 07/31/2023, at approximately at 11:55 a.m., the facility received a call from a bystander who found Resident #2 (R2) at 5740 Ralston Street and noticed R2 seemed lost and out of place. Upon receiving the information, staff picked up and returned R2 back to the facility. It was identified that R2 exited the facility through the main entrance for approximately one (1) hour prior to being located on the street. R2 was provided basic first aid for a small scrape on R2s left knuckle, and a small scrape on R2s right pinky toe. Per R2’s Physician Report dated 8/16/2022, R2 has a diagnosis of dementia and cannot leave the facility unassisted. Information gathered reflected that front desk staff were on break during the time of R2’s elopement and staff were not aware that R2 exited the facility.

During today’s visit, the LPA, Family Advisor Ashley and Wellness Director Justin discussed both incidents, Ashley stated that the two employees who previously were at the front desk have been moved to different job duties. Ashley also stated that to ensure no further elopements to occur, the Administrator is looking at different security systems to put in place, additional training for staff, and that the list at the front desk of residents who cannot leave without assistance is continuously being updated.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted, today's reports and appeal rights were reviewed and issued to Wellness Director Justin Ramirez.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/09/2023 04:55 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: LEXINGTON ASSISTED LIVING
FACILITY NUMBER: 565850111

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/10/2023
Section Cited
CCR
87705(c)(4)

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87705(c)(4) Care of Persons with Dementia (c) Licensees who accept... residents with dementia shall be responsible ...There is an adequate number of direct care staff to support each resident’s ...safety. This requirement is not met as evidenced by:
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Licensee is in the process of hiring two additional staff and shall submit written procedures outlining the steps it intends to take to ensure there is adequate staffing at all times for proper monitoring of residents with dementia. Licensee shall submit the proof of correction by no later than 08/09/2023
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Based on record review and interview, the licensee did not comply with the above section by not having sufficient staff to ensure R2 did not leave the facility unassisted per physician report, which poses an immediate health and safety risk to resident in care.
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Type B
08/23/2023
Section Cited
CCR87463(a)

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87463(a)-Reappraisals. The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes ... changes in the resident's physical, medical, mental, and social condition… This requirement is not met as evidenced by:
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Licensee agrees to update R2's reapraisal with the observed changes in conditions, notify R2's physician of concerns and get an updated LIC602. Licensee shall submit the proof of correction by no later than 8/23/2023.
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Based on interviews and record review, licensee did not comply with the section cited above as R1's reappraisal was not updated to reflect change of condition, which poses a potential health and 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: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
LIC809 (FAS) - (06/04)
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