565850111-11-6-2023-29-AS-MARO-CXBV9B-20231106151405

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850111
Report Date: 11/06/2023
Date Signed: 11/06/2023 03:14:17 PM

Document Has Been Signed on 11/06/2023 03:14 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LEXINGTON ASSISTED LIVING		FACILITY NUMBER:	565850111
ADMINISTRATOR:	ERIC TERRILL		FACILITY TYPE:	740
ADDRESS:	5440 RALSTON ST		TELEPHONE:	(805) 644-6710
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	125	CENSUS: 77	DATE:	11/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Sanjuana Enriquez / Ashley Villareal		TIME COMPLETED:	03:30 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Martha Arroyo and Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 9:40 a.m. Upon arrival, the LPAs were greeted by the front desk staff. The Business Office Manager, Mayra Gutierrez assisted LPA’s shortly after and the reason for the visit was explained. The Interim Executive Director, SanJuana Enriquez arrived during the inspection. Entrance interview conducted.

At 10:20 a.m., the LPAs along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted:

KITCHEN: The LPAs inspected the kitchen/food service area at 10:30 a.m. Knives are stored and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates.

COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 05/22/2023. The LPAs observed required postings throughout the common space. The LPAs observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. The LPA’s observed an adequate supply of emergency food and water. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed.

(Report Continued on LIC 809C...)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEXINGTON ASSISTED LIVING	FACILITY NUMBER: 565850111
	VISIT DATE: 11/06/2023

NARRATIVE

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(Report Continued from LIC 809...)

BEDROOMS: The LPAs observed the resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPAs observed a sufficient supply of towels and linens.

RESTROOMS: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water temperature was measured in eight (8) random assisted living bathrooms between 10:44 a.m. and 11:26 a.m., the temperature measured between 102.7 – 121.3 degrees Fahrenheit. Between 10:21 a.m. and 10:25 a.m., the hot water temperature was measured in two (2) random memory care bathrooms and the temperature measured between 116.9 – 118.0 degrees Fahrenheit. The water temperature was adjusted at the time of the visit.

RECORDS: LPA’s reviewed Resident Records at 11:44 a.m. and Personnel Records at 12:36 p.m.

Seven (7) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order.

Seven (7) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Out of the seven (7) files reviewed, only one (1) staff had an active first aid/CPR on file.

The last fire inspection was completed on 02/20/2022 and was found to be in compliance with Fire Code Regulations at the time of inspection. Staff will have a new inspection scheduled. Fire and earthquake drills conducted within the last 6 months as per regulation; the last one conducted 10/16/2023.

(Report Continued on LIC 809C...)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEXINGTON ASSISTED LIVING	FACILITY NUMBER: 565850111
	VISIT DATE: 11/06/2023

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(Report Continued from LIC 809C...)

MEDICATIONS: Medications review began at approximately 1:15 p.m. The medications are centrally stored in the medication room. Medications are labeled and checked for expiration dates. At 1:46 p.m., record review revealed Resident #1’s (R1’s) medication Lisinoprol’s prescription number on the bottle did not match that on the centrally stored medication and destruction record (CSMDR). Staff corrected prescription number on the CSMDR at the time of the visit.

The LPAs conducted interviews with eight (8) staff members and two (2) residents between 12pm and 1pm.

During today’s visit, the LPAs obtained copies of the following documents: Census, staff schedule, and limited liability insurance.

The following deficiencies were observed (See LIC 809-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 issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/06/2023 03:14 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
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: 11/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(6)(E)

The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes; The prescription number and the name of the issuing pharmacy. This requirement was not as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as R1’s medication’s prescription number on bottle did not match that on the CSMDR, which poses a potential health, safety, or personal rights risks to residents in care.
	POC Due Date: 11/06/2023
	Plan of Correction
1 2 3 4	The licensee had prescription number corrected at the time of the visit. POC has been met.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC809 (FAS) - (06/04)

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