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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850111
Report Date: 10/14/2021
Date Signed: 10/14/2021 06:27:30 PM

Document Has Been Signed on 10/14/2021 06:27 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: 71DATE:
10/14/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Matteo DiGrigoli - Operations ManagerTIME COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a Case Management - Deficiencies visit at the facility. LPA met with staff Matteo DiGrigoli who is authorized to review and sign reports.

During facility tour on 10/14/2021 starting at 11:35 am with staff Ashley Villareal LPA observed wound cleanser, wound gel, wound dressing, laundry detergent, cough suppressant, levetiracetam tablets, pantoprazole tablets, ibuprofen, sertraline tablets, januvia tablets, finasteride tablets, aspirin, mirtazapine tablets, tylenol, melatonin, vitamin D3, miralax, quetiapine tablets, gaviscon antacid, polyethylene glycol, laxaclear, albuterol inhaler, clopidogrel tablets, RA col-rite capsules, atorvastatin tablets, docusate sodium soft gels in an unlocked room #119 in memory care accessible to residents. During facility tour on 10/14/21 at 12:36 pm with staff DiGrigoli LPA observed staff #1 (S1) working and not associated to the facility. Staff stated that they have been working at the facility for 1 to 2 months. LPA verified through Guardian that S1 is fingerprint cleared and not associated to the facility. Staff DiGrigoli stated that they do not have any documentation of S1 being associated to the facility.

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 $750.00.

Exit interview was conducted, today's reports, civil penalties and appeal rights were reviewed and emailed to the Operations Manager
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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 3
Document Has Been Signed on 10/14/2021 06:27 PM - It Cannot Be Edited


Created By: Joann Rosales On 10/14/2021 at 02:12 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: 10/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2021
Section Cited
CCR
87705(f)(2)

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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:
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Staff locked door during facility visit. Staff stated that a key pad door lock will be placed on the door. Staff will provide documentation of door lock to CCL by 10/15/21.
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Based on LPA's observations, the licensee did not comply with the section cited above as Over-the-counter-medication, vitamins, and toxic substances were observed accessible to residents which poses an immediate health and safety risk to persons in care.
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Type A
10/15/2021
Section Cited
CCR87465(h)(2)

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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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Staff locked door during facility visit. Staff stated that a key pad door lock will be placed on the door. Staff will provide documentation of door lock to CCL by 10/15/21.
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Based on LPA's observations, the licensee did not comply with the section cited above as resident 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 Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/14/2021 06:27 PM - It Cannot Be Edited


Created By: Joann Rosales On 10/14/2021 at 02:20 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: 10/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2021
Section Cited
CCR
87355(e)(2)

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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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S1 requires to obtain criminal transfer. Staff will submit copies of criminal background clearance transfer request, LIC508 and photo identifications to CCL by 10/15/21. Staff stated that they will not employ staff unless they are associated with the facility.
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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 residents 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 Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021


LIC809 (FAS) - (06/04)
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