374604371-2-3-2023-08-AS-LTEZ-CNR2AW-20230204161412

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604371
Report Date: 02/03/2023
Date Signed: 02/03/2023 02:37:54 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/16/2022 and conducted by Evaluator Nacole Patterson

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20221216121338

FACILITY NAME:	LEXINGTON HOUSE		FACILITY NUMBER:	374604371
ADMINISTRATOR:	ASOY-DANIEL, ROSHELLE HAN		FACILITY TYPE:	740
ADDRESS:	180 W. LEXINGTON AVE.		TELEPHONE:	(619) 401-7528
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92020
CAPACITY:	6	CENSUS: 4	DATE:	02/03/2023
		UNANNOUNCED	TIME BEGAN:	02:17 PM
MET WITH:	Megan Bragg, Caregiver		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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1. Lack of supervision led to resident sustaining a fall.
2. Facility staff did not meet resident's hygiene needs.
3. Facility staff did not maintain resident's room free from debris.
4. Facility not following Covid-19 protocols.
5. Licensee did not provide resident with an updated admission agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced complaint visit to the facility to deliver findings for the above allegations. LPA introduced herself and disclosed the purpose of the visit to Megan Bragg, Caregiver

On 12/16/22 it was alleged that lack of staff supervision by facility staff led to a resident sustaining a fall, staff were not maintaining the hygiene of residents or maintaining bedrooms free from debris, staff were not following Covid-19 protocols, and the Licensee did not provide a resident with an updated admission agreement. The Department’s investigation consisted of unannounced facility tours, review of facility and outside source records, interviews with facility staff and outside sources, and LPA direct observations.

(Continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

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 4

Control Number 08-AS-20221216121338

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LEXINGTON HOUSE	FACILITY NUMBER: 374604371
	VISIT DATE: 02/03/2023

NARRATIVE

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...Continued from LIC9099

Regarding the first allegation, "Lack of supervision led to resident sustaining a fall". Direct observation by LPA as well as outside source records and interviews, showed that the facility staff had systems in place to monitor ambulatory residents, and that residents are allowed to walk around the facility, including within the perimeter gate, without line-of-sight supervision. There was no evidence of injuries for the resident in question, and additional eyewitness interviews revealed that the resident may not have actually fallen but had possibly been participating in another activity that was not related to falling, such as exercising or resting on the ground. Interviews with numerous outside service providers revealed that the caregivers were timely in their attention to each resident, including when ambulatory residents were in the outside patio area. There is no evidence to support that any resident went outside of the perimeter fence and off the facility property alone. On two unannounced facility visits Department staff directly observed the supervision of all residents by facility staff. During these visits all residents were tended to within reasonable amounts of time, and staff interviews revealed that the facility has systems in place to ensure resident supervision needs are being met, such as performing regular resident checks and utilizing the back-up caregiving staff who live on the property to assist when necessary.

Regarding the second allegation, "Facility staff did not meet resident's hygiene needs", direct LPA observations, record review, attempted interview, and outside source interviews showed that all resident hygiene needs were reasonably tended to. On two unannounced facility visits Department staff directly observed residents in care, finding all residents to be dressed in clothing free from debris, food particles, and/or stains. Staff interviews and facility documents revealed that residents are on a twice per week shower or sponge bath schedule, according to the needs outlined in their care plans. At times residents will express their personal right not to be showered, reducing the number of showers they receive each week. Service provider interviews indicated that all resident’s hygiene needs were monitored and maintained within appropriate levels based on their care plan. There is no evidence that show any resident being neglected regarding personal hygiene care.

Continued on LIC9099...

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 08-AS-20221216121338

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LEXINGTON HOUSE	FACILITY NUMBER: 374604371
	VISIT DATE: 02/03/2023

NARRATIVE

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...Continued from LIC9099-C

Regarding the third allegation, "Facility staff did not maintain resident's room free from debris", direct LPA observations, record review, and outside source interviews showed that all resident bedrooms were maintained on a daily schedule. On two unannounced facility visits Department staff directly observed all resident bedrooms, finding all spaces to be free from clutter, clothing, food particles, and/or other debris. Staff interviews and facility documents revealed that staff adhere to daily cleaning schedules, depending on their shifts. These tasks include sweeping, mopping, laundry, washing dishes, cleaning bathrooms, and cleaning resident bedrooms. Service provider interviews showed that facility staff had been observed on a regular basis to be performing their assigned cleaning tasks. There is no evidence to support that any resident bedroom was left unmaintained and/or unclean during the periods of observation by witnesses and Department staff.

Regarding the fourth allegation, "Facility not following Covid-19 protocols". Direct LPA observations, record review, and outside source interviews showed that the facility, overall, adhered to required Covid-19 protocols mandated by Community Care Licensing Division (CCLD), the California Department of Public Health (CDPH), and the Centers for Disease Control and Prevention (CDC). On two unannounced facility visits LPA directly observed a station of Personal Protective Equipment (PPE) supplies such as hand sanitizer, gloves, face masks, and thermometers at the entrance of the facility as well as in the kitchen. LPA also observed signs posted around the facility notifying employees and visitors to wear face masks, posters explaining the symptoms of Covid-19, and instructions on how to properly administer hand sanitizer. Staff were seen wearing face masks during each unannounced visit. The Department received inconsistent statements from outside source interviews regarding staff members wearing masks in non-resident areas. During one of the onsite meetings, LPAs observed staff not wearing a mask, however, it was while the staff member was eating and drinking. Department records show that the facility submitted the required Covid-19 documentation such as the Infection Control Mitigation Plan and Covid-19 vaccination implementation for staff and consenting residents. Although the Department received inconsistent statements regarding staff not wearing their masks in the facility, a preponderance of evidence does not exist to prove that the facility was out of compliance regarding Covid-19 protocols.

Continued on LIC9099-C

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20221216121338

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LEXINGTON HOUSE	FACILITY NUMBER: 374604371
	VISIT DATE: 02/03/2023

NARRATIVE

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...Continued from LIC9099-C

Regarding the fifth allegation, " Licensee did not provide resident with an updated admission agreement". Record review shows that the admission agreement in question, signed by the resident, included the appropriate Licensee information, as confirmed by the California Secretary of State website.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the 5 listed allegations are UNSUBSTANTIATED. An exit interview was conducted with caregiver Megan Bragg, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC9099 (FAS) - (06/04)

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