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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850111
Report Date: 11/18/2021
Date Signed: 11/18/2021 06:25:28 PM

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 ENRIQUEZFACILITY TYPE:
740
ADDRESS:5440 RALSTON STTELEPHONE:
(805) 644-6710
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:125CENSUS: 70DATE:
11/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Matteo DiGrigoliTIME COMPLETED:
02:36 PM
NARRATIVE
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Licensing Program Analysts (LPA) Angel Ascencio and JoAnn Rosales arrived at the facility at 10:50 a.m. unannounced to conduct a required annual visit at. This annual had a specific emphasis on infection control practices and procedures. The LPAs met with Operations Manager (OP) Matteo DiGrigoli and discussed the reason for the visit. Entrance interview conducted.

The LPAs, along with Matt, toured the physical plant areas inside and outside at 11:02 a.m. to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

BEDROOMS: The LPAs observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 125 total bedrooms; 111 (one hundred and eleven) are assisted living resident rooms and 14 (fourteen) are in memory care resident rooms.

RESTROOMS: Public and resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. The LPAs observed sufficient amounts of soap and paper products in each restroom, as well as hand washing posters. Water temperature were also checked in 5 random rooms, all of which were between 105.0 and 120.0 degree F.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPAs observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. Smoke detectors were observed to be services within the last.

Continued on LIC 809 - C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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 4
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: 11/18/2021
NARRATIVE
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The back courtyard has a covered outdoor area equipped with furniture for resident use. The facility pool gate was observed to be locked at the time of visit.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPAs spoke with the Operations Manager regarding the facility’s infection control practices during facility tour at 11:02 a.m. There are 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. LPA noted that the facility is allowing visitors for both indoor and outdoor visitation. The LPAs observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

During facility tour at 11:02 a.m., the Wellness Director room was observed to unlocked and contained various prescribed and over-the-counter medication bottles, pliers, screwdrivers and electronic duster spray that is accessible to resident which poses an immediate health, safety and personal rights violation to persons in care. Operation Manager stated the room is usually looked but perhaps a resident must have just finished using the bathtub. Operations Manager proceeded in locking the Wellness Director room. At 12:06 p.m., room 357 was observed to be unlocked which contained a Tide Laundry soap container, Dawn dishsoap and scissors accessible to resident which poses an immediate health, safety and personal rights violation to persons in care. Operation Manager stated they are unsure of what their diagnosis is and unsure whether the resident can have the supplies in their room. LPAs reviewed resident files at 12:34 p.m. and observed 6 residents with a diagnosis of dementia and cannot have access to hazardous items. The review of the 6 resident physicians report were not current within the last year.

3 citations were issued during today’s visit. The following deficiencies were observed (See LIC 9099-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.

Civil penalties were issued today, 11/18/2021 for $250.00 for repeat violation. Exit interview conducted. A copy of the report, civil penalty and appeal rights was provided via email to Operations Manager.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 11/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as pliers, screwdrivers and scissors were accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2021
Plan of Correction
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Operations Manager will provide training in cited regulation to all staff. OP will submit training material and attendees to LPA via email: angel.ascencio@dss.ca.gov.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as over the counter and prescription bottles, laundry soap and dish soap were found in an unlocked room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2021
Plan of Correction
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Operations Manager will provide training in cited regulation to all staff. OP will submit training material and attendees to LPA via email: angel.ascencio@dss.ca.gov.
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: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 11/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as 6 out of 70 total residents did not have a current Physician's Report which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/03/2021
Plan of Correction
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Operations Manager will help facilitate the renewal of the Physician's report. Newest reports will be submitted to LPA via email: angel.ascencio@dss.ca.gov.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4