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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850111
Report Date: 05/22/2024
Date Signed: 05/22/2024 06:40:07 PM


Document Has Been Signed on 05/22/2024 06:40 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 LIVINGFACILITY NUMBER:
565850111
ADMINISTRATOR:SANJUANA JOANNA ENRIQUEZFACILITY TYPE:
740
ADDRESS:5440 RALSTON STTELEPHONE:
(805) 644-6710
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:125CENSUS: 56DATE:
05/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jill Morris ChapmanTIME COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management – Deficiency visit in conjunction with complaint visit (CC #29-AS-20231020083938). LPA Arroyo met with Executive Director, Jill Morris Chapman. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.

The facility was not able to provide all of Resident #1’s (R1s) medication records and advised that they archived all records and marked medications as “discontinued” when the residents move out or expire.

Citation issued, exit interview, appeal rights given.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/22/2024 06:40 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: 05/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
Section Cited
CCR
87506(a)(e)

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A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information...

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Licensee will submit plan how you will ensure resident records are maintained for a minimum of three (3) years and readily available to licensing staff. Submit to CCL no later than 05/31/2024.
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...(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.
This requirement is not met as evidenced by:
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During the complaint investigation, the facility was unable to provide all of R1’s records, which posed 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: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2