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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850111
Report Date: 04/12/2022
Date Signed: 04/12/2022 04:32:07 PM

Document Has Been Signed on 04/12/2022 04:32 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: 68DATE:
04/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Sanjuana EnriquezTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a Case Management - Deficiencies visit at the facility. LPA met with Administrator Sanjuana Enriquez.

During facility tour on 4/12/22 starting at 12:06 pm with the Administrator LPA observed Dawn dishwashing liquid in the memory care laundry room accessible to residents. During facility tour with Administrator on 4/12/22 at 12:11 pm LPA observed staff #1 (S1) working and not associated to the facility. S1 stated that they have been working at the facility for 2 months. Administrator stated that S1 starting working at the facility on 2/14/22.

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 and and $3000.00.

Exit interview was conducted, today's reports, civil penalties and appeal rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/12/2022 04:32 PM - It Cannot Be Edited


Created By: Joann Rosales On 04/12/2022 at 03:43 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: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/13/2022
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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Administrator locked laundry room door during facility visit. Administrator stated that place self locking mechanism on laundry door and will provide documentation to CCL by 4/13/22.
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Based on LPA's observations, the licensee did not comply with the section cited above as dishwashing liquid was observed accessible to residents which poses an immediate health risk to persons in care.
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Type A
04/12/2022
Section Cited
CCR87355(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. Administrator associated S1 through Guardian System during the facility visit. Administrator 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 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: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


LIC809 (FAS) - (06/04)
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