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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850111
Report Date: 08/22/2024
Date Signed: 08/22/2024 03:14:55 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
02/01/2023 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20230201105127
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: 57DATE:
08/22/2024
UNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Martha Bishop, Marketing DirectorTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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9
Staff member inappropriately handled resident
Staff not answering call lights timely
Staff member spoke to resident inappropriately
Staff unable to communicate with resident
Food is inadequate in quantity and quality
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek arrived unannounced to conduct a subsequent complaint visit. The LPA met with Marketing Director and explained the reason for the visit. Executive Director Jill Chapman was unavailable during today's visit. Entrance interview conducted.

During today's visit, LPA obtained additional records and conducted a brief tour of the facility. During an initial complaint visit conducted on 02/06/2023, the LPA conducted an interview with Community Liason Director Ashley Villareal at 10:55AM, the LPA reviewed and obtained copies of pertinent documents, toured the facility along with Ashley Villareal at 11:18AM, viewed lunch service at 11:36AM, and conducted interviews with residents and staff from 11:38AM to 4:00PM. No health and safety hazards were identified during the visit. Throughout the course of the investigation, LPA reviewed relevant documents. The following was then determined:

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
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 8
Control Number 29-AS-20230201105127
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: 08/22/2024
NARRATIVE
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Continued from LIC 9099 (p.1)

Allegation: "Staff member inappropriately handled resident:"
The complaint alleges that staff handled Resident #1 (R1) roughly while transferring R1 to their wheelchair. LPA interviewed R1, who indicated that while some of the staff are really nice and gentle, there are some who twist and pull her arm, which hurts R1. LPA reviewed R1's physician's report and resident assessment. R1 has a diagnosis of dementia and physician's report indicates R1 has motor impairment/paralysis with a note stating "right arm movement." Resident did report to LPA that they have difficulty with their right arm, which makes dressing difficult. R1's physician's report and care assessment indicate R1 requires assistance with dressing and grooming as well as transfer assistance. Staff interview revealed that as R1 has limited mobility with their right arm, it is difficult to assist R1 with dressing and transfers, but that staff are gentle with R1 when providing care. Staff interviewed indicated that R1 hits the caregivers when they come into R1's room to provide care. R1 stated to LPA that R1 had not informed the caregivers that R1 has pain in their right arm and to avoid moving that arm when possible. However, later in the interview, R1 stated R1 threatened to hit the caregivers if they did touch her right arm. Interview with various residents revealed that staff are kind and gentle when assisting with care needs. Based on interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation "staff member inappropriately handled resident" is deemed UNSUBSTANTIATED at this time.

Allegation: "Staff not answering call lights timely:"
The complaint alleges that when R1 called for assistance the staff do not respond timely. Record review revealed that R1 moved into the facility on 01/22/2023. Interviews revealed that prior to moving into the facility, R1 was residing in a private residence with a private 1:1 caregiver. Staff interviewed indicated that R1 was used to having a 1:1 staff, but that the facility does not have a 1:1 ratio. In the facility, there are 3 caregivers staffed at a time and that at times, although they hear a call, staff are busy assisting other residents and they have to wait up to 10 (ten) minutes for a response. Residents interviewed indicated that there are some times that are busier than others, but that typically the response time is pretty quick. Residents interviewed felt their needs were met timely and had no concerns with response time. Staff interviews revealed that the facility is fully staffed, no agency staffing was being used at the time of the complaint and that all staff are trained in the facility's policies regarding call response times. Based on
Continued on LIC 9099-C (p.3)
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 29-AS-20230201105127
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: 08/22/2024
NARRATIVE
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Continued from LIC 9099-C (p.2)

interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation "staff not answering call lights timely" is deemed UNSUBSTANTIATED at this time.

Allegation: "Staff member spoke to resident inappropriately:"


The complaint alleges that a member of the management staff yelled at R1 while in the elevator. LPA interviewed staff and residents regarding this allegation. R1 could not recall an incident where any member of management raised their voice or yelled at R1, stating "no they don't yell. I may yell because my husband couldn't hear, but they don't yell. They just don't listen." R1 had no recollection of an incident in the elevator. Staff interviewed have never witnessed any staff yell or be disrespectful with R1 or any other residents. Residents interviewed indicated the staff are nice and they have never heard staff yelling at residents. Although the allegation may be valid, based on interview, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation that "staff member spoke to resident inappropriately" is deemed UNSUBSTANTIATED at this time.

Allegation: "Staff unable to communicate with resident:"


The complaint alleges that staff do not speak English and were not able able to communicate with R1. Interview with R1 revealed that there is a particular staff who "speaks Mexican" and did not understand R1. Interview with staff revealed that there are staff working at the facility that do not speak English as their primary language, however, when providing care to R1, the staff indicated in the complaint does take another staff with them into the room to help with any translation that might be needed. R1 confirmed that during the alleged incident that another staff was present and able to communicate with R1. During staff interviews, LPA was able to understand all staff interviewed. Residents interviewed indicated they have no problems related to staff communication or a language barrier. Based on interview, there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation "staff unable to communicate with resident" is deemed UNSUBSTANTIATED at this time.

Allegation: "Food is inadequate in quantity and quality:"


LPA interviewed staff and residents with regard to food. R1 did indicate that on the date of the LPA's initial visit, that R1 had fallen asleep in the recliner chair, so when R1 awoke from their nap to eat, the breakfast

Report Continued on LIC 9099-C (p. 4)

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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
02/01/2023 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20230201105127

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: 57DATE:
08/22/2024
UNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Martha Bishop, Marketing DirectorTIME COMPLETED:
03:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not assist resident with self-administration of medications as prescribed
Staff did not shower resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
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13
Licensing Program Analyst (LPA) Kelly Dulek arrived unannounced to conduct an subsequent complaint visit. The LPA met with Marketing Director and explained the reason for the visit. Executive Director Jill Chapman was unavailable during today's visit. Entrance interview conducted.

During today's visit, LPA obtained additional records and conducted a brief tour of the facility. During an initial complaint visit conducted on 02/06/2023, the LPA conducted an interview with Community Liason Director Ashley Villareal at 10:55AM, the LPA reviewed and obtained copies of pertinent documents, toured the facility along with Ashley Villareal at 11:18AM, viewed lunch service at 11:36AM, and conducted interviews with residents and staff from 11:38AM to 4:00PM. No health and safety hazards were identified during the visit. Throughout the course of the investigation, LPA reviewed relevant documents. The following was then determined:

Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 29-AS-20230201105127
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: 08/22/2024
NARRATIVE
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Continued from LIC 9099-A (p.5)

Allegation: "Staff did not assist resident with self-administration of medications as prescribed:"


The complaint alleges that R1 did not receive medication assistance for the first few days when they moved into the facility. Documents reviewed indicate that R1 was tentatively scheduled to move into the facility on Friday 01/20/2023, however, interview revealed that R1 moved in on Sunday 01/22/2023 at 04:00PM. LPA spoke with the medication technician who was in charge of the facility on Sunday. Interview revealed that R1's medications were brought to the front desk when R1 moved in on Sunday afternoon. Medication technician picked up the medications and administered the appropriate medications to R1 that evening. R1's medications were not immediately entered into the computer system, since the Wellness Director was not present at the time of R1's move in. Interview revealed that due to this, staff logged R1's medications on a paper Medication Administration Record (MAR) rather than the electronic MAR until R1's medications were input into the computer. LPA reviewed documents for R1, which did reflect medications recorded in the electronic system beginning Monday 01/23/2023 at 08:00PM. However, paper MAR records for Sunday and Monday were unable to located, nor was R1's centrally stored medication and destruction record (CSMDR). Additionally, although R1's medication list was provided, there were no quantities of medications listed, so there is no way of knowing which medications, if any, were administered during this time period. Interview with staff revealed that R1 was not given medications on Monday until R1's family member was at the facility Monday evening yelling at the staff. Based on interview and record review, the allegation that "staff did not assist resident with self-administration of medications as prescribed" is deemed SUBSTANTIATED at this time.

Allegation: "Staff did not shower resident:"
The complaint alleges that R1 did not receive a shower during their first week residing at the facility. Interview with R1 revealed that staff did not offer a shower "not at all" to R1 during that time period. Interview with staff revealed that typically residents are placed on the shower schedule the day of move in or the following day. R1 moved in at 04:00PM on a Sunday, so staff interviewed surmised that R1 was likely placed on the schedule on Monday once the staff got to know the resident and her shower preference. R1 was on the schedule on Tuesday and Friday in the afternoon shift for shower assistance. Interview with R1 revealed that now staff tell R1 that their daughter insists R1 showers, so R1 does comply with the current twice a week shower schedule, but again reiterated that no showers were offered in the first week R1 resided at the facility.

Report Continued on LIC 9099-C (p.7)

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 29-AS-20230201105127
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: 08/22/2024
NARRATIVE
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Continued from LIC 9099-C (p.6)

R1's assessment indicates that R1 requires physical assist with bathing twice weekly. Staff interviewed stated that R1 was showered once during that first week and was unsure what occurred with the second shower. Staff indicated that likely R1 refused, but that shower refusals are documented. The facility was unable to provide any written proof that R1 had refused a shower during that time period. Documents provided indicated R1 received a shower on their 8th day residing at the facility. Therefore, based on interview and record review, there is sufficient evidence to support the allegation and the allegation that "staff did not shower resident" is deemed SUBSTANTIATED at this time.

Pursuant to Title 22 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D):



Exit interview conducted. A copy of the report and appeal rights were reviewed and provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 29-AS-20230201105127
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: 08/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care
(a) (4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
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Previous management indicated a retraining of all staff was conducted following the incident. POC cleared.
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Based on interview and record review, the licensee did not comply with the above cited section, as R1 moved into the facility on 01/22/2023 and medications were not documented as administered until 01/24/2023, which posed a potential health and safety risk to persons in care.
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Type B
08/22/2024
Section Cited
CCR
87464(f)(4)
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87464 Basic Services (f) (4) Personal assistance and care as needed by the resident and as indicated in the preadmission appraisal, with those activities of daily living such as dressing, eating, bathing...
This requirement is not met as evidenced by:
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Management staff indicated the facility now has a new computerized system to track all ADL care needs being provided to residents to ensure this does not happen in the future. POC cleared.
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Based on interview and record review, R1 required assistance with 2 showers per week and according to documents reviewed, R1 did not reveive a shower for 8 days following move in, which poses a potential health and personal rights risk to persons 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 29-AS-20230201105127
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: 08/22/2024
NARRATIVE
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Continued from LIC 9099-C (p.4)

that R1 had ordered and had been delivered was cold. R1 stated that often R1's food is cold when R1 is ready to eat. R1 stated if staff are available, they are able to reheat the food for R1 in a microwave provided in R1's room. Other residents interviewed indicated that for the most part they are happy with the food and feel it is of adequate quality and quantity. Residents indicated they have a choice in the meal provided and can order from an alternate menu should they choose. LPA observed lunch service and noted the meal did contain food from all food groups and residents appeared to enjoy their meal. The LPA observed sufficient amounts of varied food choices in all food groups, as well as emergency food and water available at the facility during the visits. Staff interviewed indicated that R1 chooses not to eat in the dining room and instead orders food to be delivered. Often, R1 falls asleep prior to ordering the meal in the morning or while the meal is being prepared. Staff did deliver a microwave to R1's room and will assist in heating the food at R1's request. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation "food is inadequate in quantity and quality" is deemed UNSUBSTANTIATED at this time.

No citations issued related to the above allegations. Exit interview conducted. A copy of today's report was provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8