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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850111
Report Date: 05/22/2024
Date Signed: 05/22/2024 06:52:58 PM

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
10/20/2023 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20231020083938
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: 56DATE:
05/22/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jill Morris ChapmanTIME COMPLETED:
07:00 PM
ALLEGATION(S):
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9
Neglect/Lack of Care and Supervision: Facility staff failed to provide medication for Resident #1 (R1) which contributed to R1’s death.
Staff did not ensure a resident's pendent was properly functioning while in care.
Staff did not communicate effectively with an authorized representative.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA Arroyo met with Executive Director, Jill Morris Chapman and explained the reason for the visit.

On 10/20/2023, the Department received a complaint regarding an allegation of Neglect/Lack of Care and Supervision. It was alleged that facility staff failed to provide medication for Resident #1 (R1) which contributed to R1’s death. Concerns were that R1 was not receiving proper medications from the facility which caused a major stroke leading to death. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Laarni Santiago.

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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 9
Control Number 29-AS-20231020083938
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: 05/22/2024
NARRATIVE
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Continued from LIC 9099...

On 10/23/2023, from 10:00 a.m. to 3:30 p.m., LPA Arroyo arrived unannounced to conduct the initial 10-Day complaint visit. During the visit, the LPA conducted a tour of the facility to ensure there were no health and safety concerns at 10:20 a.m., conducted a file review at 11:00 a.m., obtained copies of pertinent documents relevant to the investigation, and conducted interviews with three (3) staff and nine (9) random residents between 2:00 p.m. and 3:00 p.m.

During today’s visit, LPA Arroyo conducted interviews with three (3) staff, four (4) randomly selected residents, and two (2) randomly selected resident responsible persons between 10:53 a.m. and 2:09 p.m. and obtained copies of pertinent documents.

Investigator Santiago conducted interviews on 11/22/2023, at approximately 2:48 p.m., with R1’s Resident Representative (RP); on 11/30/2023, from approximately 9:45 a.m. to 4:15 p.m., with various facility staff and former staff; on 12/01/2023, from approximately 5:15 a.m. to 7:51 a.m., with facility med techs and R1’s pain management physician; on 01/12/2024, from approximately 11:00 a.m. to 11:58 a.m., with the administrator and med tech; on 01/17/2024, at approximately 4:13 p.m., with R1’s primary care physician (PCP); on 01/19/2024, at approximately 9:41 a.m., with a former staff; and on 03/19/2024, from approximately 10:30 a.m. to 12:35 p.m., with R1’s resident representative and pharmacist. In addition, the investigator reviewed medical records from St. John’s Regional Medical Center, Ojai Health and Rehabilitation, Community Memorial Hospital (CMH), Pacific Pain Management, Inc., Ventura County Medical Center, County of Ventura Certificate of Death, and facility file documents related to the investigation.



According to R1’s physician report, dated 03/09/2023, the primary diagnosis was listed as Chronic Obstructive Pulmonary Disease (COPD), secondary diagnosis listed as aortic/valve stenosis, HTI, depression, diabetes mellitus, and back pain. The report indicated R1’s mental condition as being able to communicate needs and able to follow instructions. R1 was not able to administer prescription medications, injections, perform their own glucose testing, PRN medications, or store their medications. The report lists R1 as ambulatory and can independently transfer to and from bed. The preplacement appraisal information indicated no diet limit, and medication managed by the facility.

Continued on LIC 9099C...
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
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 29-AS-20231020083938
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: 05/22/2024
NARRATIVE
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Continued from LIC 9099C...

During the investigation, interviews were conducted with R1’s RP, medical providers, facility staff and outside sources. Medical and facility records were also obtained and reviewed. R1’s death certificate revealed that R1 died on 06/22/2023 of acute respiratory failure with hypoxia, aspiration pneumonia and acute ischemic stroke. R1’s PCP indicated that R1’s history of transient ischemic accident (TIA) could have contributed to a cerebral vascular accident (CVA) and not due to missing R1’s stroke prevention medication. The PCP also denied that any of R1’s medications contributed to R1’s death. R1’s PCP stated that the reason for the acute respiratory failure with hypoxia was due to pneumonia. Evidence obtained from hospital records revealed that after the medical provider consulted with R1’s resident representatives about the poor prognosis, they decided to place R1 on comfort care and was later extubated on 06/20/2023. Furthermore, R1’s pain management doctor indicated that although R1 revealed similar symptoms of buprenorphine (suboxone) withdrawal, the doctor could not confirm that it was due to not receiving those medications. Medical records further corroborate that R1 did not present any signs of opiate withdrawal.

Based on interviews and records review, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation “Neglect/Lack of Care and Supervision: Facility staff failed to provide medication for Resident #1 (R1) which contributed to R1’s death” is deemed Unsubstantiated at this time.

It was alleged that staff did not ensure a resident’s pendant was properly functioning while in care. It was reported that resident was left with a pendant that didn’t work causing long wait times for someone to respond. Records reviewed and interviews conducted revealed that the facility is actively testing the residents’ pendants throughout the month to ensure they are working properly. Additionally, there is a tablet available by the front desk which is used by staff to conduct the monthly pendant testing. Staff further added that pendants displaying a battery life of 25% or less, will typically have the batteries replaced before they run out. Interviews conducted with random residents revealed that they use the pendants provided by the facility whenever they need assistance from the staff. Furthermore, residents added that although it may take a while before staff respond to the call, they know the pendants are working as the staff still arrive and check in at some point. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff did not ensure a resident’s pendant was properly functioning while in care”. Therefore, this allegation is deemed Unsubstantiated at this time.

Continued on LIC 9099C...

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
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 29-AS-20231020083938
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: 05/22/2024
NARRATIVE
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Continued from LIC 9099C...

It was further alleged that staff did not communicate effectively with an authorized representative. It was reported that resident’s responsible person was never called once regarding any issues that pertained to resident. During staff interviews, staff stated that resident’s responsible person is usually notified shortly after an incident has occurred. Interviews further revealed that different staff members are responsible for communicating certain information with the resident’s responsible person. If any information involving medications need to be discussed with the resident’s responsible person, either the Wellness Director or Wellness Coordinator will communicate with the resident’s responsible person. Similarly, if it involves notifying them of an incident during the night, the night medication technician will be the person communicating with the resident’s responsible person. Interviews conducted with random resident’s responsible person revealed that the facility does reach out to them after the resident has been involved in an incident at the facility. Responsible persons also added that the facility does in fact communicate when needed. Based on interviews conducted with facility staff and residents’ responsible persons, the Department does not have sufficient evidence to support the allegation of “staff did not communicate effectively with an authorized representative”. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted, copy of this report issued.
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
LIC9099 (FAS) - (06/04)
Page: 4 of 9
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
10/20/2023 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20231020083938

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: 56DATE:
05/22/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jill Morris ChapmanTIME COMPLETED:
07:00 PM
ALLEGATION(S):
1
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Neglect/Lack of Care and Supervision: Facility staff failed to provide medication for Resident #1 (R1).

Neglect/Lack of Care and Supervision: Facility staff failed to attend to Resident #1’s (R1’s) request for assistance in a timely manner.
INVESTIGATION FINDINGS:
1
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Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Arroyo met with Executive Director, Morris Chapman and explained the reason for the visit.

On 10/20/2023, the Department received a complaint regarding allegations of Neglect/Lack of Care and Supervision. It was alleged that facility staff failed to provide medication for Resident #1 (R1) and facility staff failed to attend to (R1’s) request for assistance in a timely manner. Concerns were that R1 did not receive their Buprenorphine medication. Furthermore, the facility did not fill R1’s prescribed medications (Baby Aspirin and Ticagrelor) when R1 was discharged from a rehabilitation facility on 05/18/2023. Concerns were that these medications helped prevent blood clots since R1 had a history of a stroke.

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: 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.
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 29-AS-20231020083938
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: 05/22/2024
NARRATIVE
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Continued from LIC 9099...

The complaint alleged that between 05/02/2023, to 06/22/2023, R1 was in and out of the hospital due to not receiving the proper medications from the Lexington Assisted Living facility. Additional concerns were that facility staff sometimes took 35 minutes or more to respond to R1’s pendant request. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Laarni Santiago.

On 10/23/2023, from 10:00 a.m. to 3:30 p.m., LPA Arroyo arrived unannounced to conduct the initial 10-Day complaint visit. During the visit, the LPA conducted a tour of the facility to ensure there were no health and safety concerns at 10:20 a.m., conducted a file review at 11:00 a.m., obtained copies of pertinent documents relevant to the investigation, and conducted interviews with three (3) staff and nine (9) random residents between 2:00 p.m. and 3:00 p.m.

During today’s visit, LPA Arroyo conducted interviews with three (3) staff, four (4) randomly selected residents, and two (2) randomly selected resident responsible persons between 10:53 a.m. and 2:09 p.m. and obtained copies of pertinent documents.

Investigator Santiago conducted interviews on 11/22/2023, at approximately 2:48 p.m., with R1’s Resident Representative (RP); on 11/30/2023, from approximately 9:45 a.m. to 4:15 p.m., with various facility staff and former staff; on 12/01/2023, from approximately 5:15 a.m. to 7:51 a.m., with facility med techs and R1’s pain management physician; on 01/12/2024, from approximately 11:00 a.m. to 11:58 a.m., with the administrator and med tech; on 01/17/2024, at approximately 4:13 p.m., with R1’s primary care physician (PCP); on 01/19/2024, at approximately 9:41 a.m., with a former staff; and on 03/19/2024, from approximately 10:30 a.m. to 12:35 p.m., with R1’s resident representative and pharmacist. In addition, the investigator reviewed medical records from St. John’s Regional Medical Center, Ojai Health and Rehabilitation, Community Memorial Hospital (CMH), Pacific Pain Management, Inc., Ventura County Medical Center, Electronic medication administration record (E-Mar), pendent alert record, and facility file documents related to the investigation.



Continued on LIC 9099C...
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
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 29-AS-20231020083938
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: 05/22/2024
NARRATIVE
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Continued from LIC 9099C...

According to R1’s physician report, dated 03/09/2023, the primary diagnosis was listed as Chronic Obstructive Pulmonary Disease (COPD), secondary diagnosis listed as aortic/valve stenosis, HTI, depression, diabetes mellitus, and back pain. The report indicated R1’s mental condition as being able to communicate needs and able to follow instructions. R1 was not able to administer prescription medications, injections, perform their own glucose testing, PRN medications, or store their medications. The report lists R1 as ambulatory and can independently transfer to and from bed. The preplacement appraisal information indicated no diet limit, and medication managed by the facility.

On the allegation “Neglect/Lack of Care and Supervision: Facility staff failed to provide medication for Resident #1 (R1)”. During the investigation, interviews were conducted with R1’s RP, facility staff, medical providers, and outside sources. It was alleged that R1 did not receive Buprenorphine medication on 04/20/23 to 04/22/2023 and 04/26/2023 to 04/30/2023. The Electronic medication administration record (E-Mar) showed that those dates were marked “X” denoting that it is “inactive.” However, pharmacy staff verified that they received prescription orders on 04/19/2023, but insurance declined to approve since it revealed that R1’s Buprenorphine had not reached the end of its previous refill. Therefore, the medications could not be released at the facility. Although the med-tech refuted the claim that R1 did not receive their medications on those dates despite the “inactive” status, Investigator Santiago could not corroborate based on interviews and the E-Mar that the medications were or were not received, or that there were still medications available at the facility. However, in May of 2023, R1 was admitted to the hospital on 05/03/2023, and transferred to a rehab facility on 05/11/2023. R1 was discharged back to the facility on 05/23/2023, with new medication orders that included Aspirin 81mg and Ticagrelor among others. Evidence obtained from Lexington’s pharmacy revealed that the only time they received a prescription for Aspirin 81 mg was on 06/07/2023, which was delivered to the facility on 06/08/2023. Furthermore, pharmacy staff confirmed that they never delivered the Ticagrelor to the facility as they never received proper authorization from R1’s cardiologist. R1’s E-mar did not document that any of those medications were given to R1 after R1 returned to the facility on or around 05/22/2023. In addition, R1’s E-Mar was not updated with new medication orders and the facility did not document that R1 received any of their medications when R1 returned to the facility around 05/22/2023 to 05/28/2023, prior to another hospital stay.

Continued on LIC 9099C...
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
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 29-AS-20231020083938
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: 05/22/2024
NARRATIVE
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Continued from LIC 9099C...

Therefore, evidence obtained from the medication and hospital record does not corroborate that R1 received all their medications while at the facility. It was evident that R1 did not receive their Ticagrelor and Aspirin medications until it (aspirin) was delivered to the facility on 06/08/2023. Therefore, based on information gathered from interviews and pertinent records, the allegation “Facility staff failed to provide medication for Resident #1 (R1)” is deemed Substantiated at this time.

On the allegation “Neglect/Lack of Care and Supervision: Facility staff failed to attend to Resident #1’s (R1’s) request for assistance in a timely manner”. Interviews were conducted with residents, R1’s resident representatives and staff. A review of the pendant alert record was also obtained and reviewed. A review of the pendant alert record revealed that there were some calls that took about 20 minutes to an hour to respond. Interviews with staff revealed that they tried to respond immediately depending on the level of priority, such as an emergency. Although the records revealed that some alerts took longer to respond to than others, the time stamp did not necessarily mean that they did not tend to the resident right away. Staff indicated that there were times when they didn’t clear the pendants immediately, which could mean that they tended to the resident first before clearing the pendant or forgot to reset the pendant. However, multiple staff admitted that they took a while to respond to residents, sometimes as long as 30 minutes to an hour to respond, due to lack of staffing. Although the residents denied expressing any concerns about staff failing to tend to their needs in a timely manner, the staff’s admission yielded that there were not enough staff present to provide sufficient supervision and respond in a timely manner. Therefore, based on the information gathered, the allegation “Neglect/Lack of Care and Supervision: Facility staff failed to attend to Resident #1’s (R1’s) request for assistance in a timely manner” is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D)

Exit interview conducted, appeal rights discussed, and a copy of this report issued.
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
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 29-AS-20231020083938
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: 05/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2024
Section Cited
CCR
87465(a)(4)
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(a)A plan for incidental medical and dental care shall be developed by each facility... and provide for assistance in obtaining such care(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Licensee will submit a plan how you will ensure residents will receive medications as prescribed. Submit to CCL no later than 05/31/2024.
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Based on records review and interviews, the licensee did not comply with the section cited above. Facility staff failed to provide R1’s Buprenorphine, Ticagrelor, and aspirin as prescribed, which posed an immediate health and safety risk to residents in care.
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Type A
05/22/2024
Section Cited
CCR
87468.2(a)(4)
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(a) In addition to the rights listed in Section 87468.1. Residents shall have all of the following personal rights: (4) To care, supervision, and services that are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:
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Licensee will submit an LIC500 Personnel Report which reflects there is an adequate amount of staffing 24/7. Submit to CCL no later than 05/31/2024.
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Based on records review and interviews, the licensee did not comply with the section cited above. Facility staff failed to respond to R1 in a timely manner, which posed an immediate 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
LIC9099 (FAS) - (06/04)
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