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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850111
Report Date: 02/24/2022
Date Signed: 02/24/2022 06:38:07 PM


Document Has Been Signed on 02/24/2022 06:38 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 ENRIQUEZFACILITY TYPE:
740
ADDRESS:5440 RALSTON STTELEPHONE:
(805) 644-6710
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:125CENSUS: 75DATE:
02/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Matteo DiGrigoliTIME COMPLETED:
06:15 PM
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a Case Management - Deficiencies visit at the facility. LPA met with Matteo DiGrigoli Operations Manager who is authorized to review and sign reports.

During facility tour on 2/24/22 starting at 10:08 am with the Operations Manager LPA observed scissors, disinfectant, dish soap, wall texture and a knife in the memory care unit kitchen accessible to residents as the door was unlocked. Operations Manager stated that they normally keep the door locked. During facility tour at 10:33 am with Operations Manager LPA observed aspirin, clopidogrel tablets, ferrous sulfate tablets, pantoprazole tablets, dulcolax stool softener, aspirin, brown seaweed in resident #2 (R2's) room accessible to residents as R2's door was open. During facility tour at 10:46 am with Operations Manager LPA observed glass cleaner, texture spray, screwdrivers, muti surface cleaner, hammer and wrenches in empty room 363 with open door accessible to residents. During facility tour with Operations Manager LPA observed staff #1 (S1) working and not associated to the facility. S1 stated that they have been working at the facility for 2 weeks. LPA verified through Guardian that S1 is fingerprint cleared and not associated to the facility. Administrator stated that S1 worked at the facility on 1/31, 2/6, 2/9, 2/10, 2/12, 2/13, 2/15, 2/16, 2/17, 2/19, 2/20, 2/21 and 2/22/22.

During the complaint investigation of complaint #29-AS-20210226132843, it was disclosed to Investigator Dennis Douglas that R1 began residency at the facility on 03/01/2020. However, the Facility Wellness Director Lidia Padilla acknowledged that R1’s Needs and Services Plan had not been updated until the most recent fall on 04/21/2021. The Needs and Services Plan had not been updated to reflect R1’s change of condition and assessment for possible higher level of care due to frequent falls and cognitive decline. R1 experienced multiple falls and sustained injuries during the time period from August 2020 to April 2021. Additionally, R1 was moved to the memory care portion of the facility in November 2020.

Continued on 809C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
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 5


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: 02/24/2022
NARRATIVE
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Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Civil penalties issued in the amount of $250.00, $250.00 and $1300.00.

Exit interview was conducted, today's reports, civil penalties and appeal rights were reviewed and emailed to the Operations Manager
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/24/2022 06:38 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: 02/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2022
Section Cited

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87705 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:
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Based on LPA's observation, the licensee did not comply with the section cited above as scissors were accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
02/25/2022
Section Cited

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87465 Incidental Medical and Dental Care Services (h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
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Based on LPA's observations, the licensee did not comply with the section cited above as R2's medications were observed accessible to residents which poses an immediate health and safety 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: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 02/24/2022 06:38 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: 02/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2022
Section Cited

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87309 Storage Space(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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Based on LPA’s observations, the licensee did not comply with the section cited above as disinfectants, cleaning solutions and other items which could pose a danger were accessible to residents which posed an immediate health and safety risk to persons in care.
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Type A
02/24/2022
Section Cited

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87355 Criminal Record Clearance. (e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c) or...
This requirement is not met as evidenced by:
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Based on interviews, the licensee did not comply with the section cited above as the licensee did not ensure that S1 was associated prior to allowing S1 to work, which poses an immediate safety 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: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 02/24/2022 06:38 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: 02/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2022
Section Cited

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87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition….
This requirement was not met as evidenced by:
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Based on documentation review, the licensee did not comply with the section cited above as R1’s Needs and Services Plan was not updated to reflect a change of condition which poses a potential health and safety 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: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5