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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850111
Report Date: 07/27/2022
Date Signed: 07/27/2022 02:36:21 PM

Document Has Been Signed on 07/27/2022 02:36 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:
07/27/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Martha ReynoldsTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control #29-AS-20220726081704 The LPA met with Clinical Resource Martha Reynolds.

At 11:28 a.m., the LPA observed that the door to the facility's in-ground pool was unlocked. The LPA brought this to the attention of Ms. Reynolds at 11:43 a.m., whom contacted facility staff to engage the lock. The LPA observed that the lock was engaged thereafter.

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 $500 for the zero-tolerance violation.

Exit interview conducted. A copy of the report, appeal rights, and civil penalties were issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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 07/27/2022 02:36 PM - It Cannot Be Edited


Created By: Ashley Smith On 07/27/2022 at 01:55 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: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2022
Section Cited
CCR
87705(e)

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87705(e) Care of Persons with Dementia. Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes.

This requirement is not met as evidenced by:
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Staff agreed to do the following:
Staff ensured that the gate was locked upon observation.

Plan of Correction met. Zero Tolerance violation; a civil penalty was assessed during today's visit.
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Based on observation, the licensee did not comply with the section cited above, as the gate leading to the swimming pool was not locked, 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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


LIC809 (FAS) - (06/04)
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