<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850111
Report Date: 09/13/2021
Date Signed: 09/13/2021 05:15:36 PM

Document Has Been Signed on 09/13/2021 05:15 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: 70DATE:
09/13/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Matteo Digrigoli - Operations ManagerTIME COMPLETED:
04:53 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
This Case management visit was conducted to address the deficiencies noted during complaint control # 29-AS-20210910084322 investigation visit conducted on 9/13/21.

During facility tour on 9/13/2021 starting at 11:02 am with Operations Manager LPA observed clorox bleach cleaner and scissors in the business office accessible to residents. Starting at 11:04 am LPA observed Tide pods in the memory care laundry room, scissors, dish detergent, windex, perineal & skin cleanser in memory care room 132 accessible to residents. At 11:41 am LPA observed disinfectant spray, isopropyl alcohol and barbicide in beauty salon accessible to residents. At 11:45 am LPA observed disinfectant spray in staff break room accessible to residents. At 12:04 pm LPA observed aspirin, clopidogrel tablets, miralax, and hydrocortisone cream in resident #1 (R1's) room accessible to residents.

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

Exit interview was conducted, today's reports and appeal rights were reviewed and emailed to the Operations Manager.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2021
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 2
Document Has Been Signed on 09/13/2021 05:15 PM - It Cannot Be Edited


Created By: Joann Rosales On 09/13/2021 at 04:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEXINGTON ASSISTED LIVING
FACILITY NUMBER: 565850111

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2021
Section Cited
CCR
87705(f)(2)

1
2
3
4
5
6
7
87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: 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:
1
2
3
4
5
6
7
Staff placed items in an inacessible location and locked doors during facility visit. Staff stated that they will provide documentation of staff training regarding regulation 87705(f)(2) by 9/24/21.
8
9
10
11
12
13
14
Based on LPA's observations and record review, the licensee did not comply with the section cited above as medication, alcohol, cleaning supplies and disinfectants were observed accessible to residents which poses an immediate safety risk to persons in care.
8
9
10
11
12
13
14
Type A
09/14/2021
Section Cited
CCR87465(h)(2)

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
Staff locked R1's bedroom door during facility visit. Staff stated that they will provide documentation of staff training regarding regulation 87465(h)(2) by 9/24/21.
8
9
10
11
12
13
14
Based on LPA's observations, the licensee did not comply with the section cited above as R1's medications were observed accessible to other residents which poses an immediate safety risk to persons in care.
8
9
10
11
12
13
14
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 Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2