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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850111
Report Date: 08/08/2022
Date Signed: 08/08/2022 05:46:00 PM

Document Has Been Signed on 08/08/2022 05:46 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:
08/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Sanjuana EnriquezTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced Case Management visit to the facility. LPA met with Administrator Sanjuana Enriquez and Executive Director Eric Terrill. This case management visit is being conducted to an discuss alleged incident that was reported to Community Care Licensing on 8/5/22 regarding resident #1 (R1) and R2.

During today's visit LPA toured the facility with Executive Director Eric Terrill, interviewed random residents and staff, review resident records and obtained copies of pertinent documents. LPA will need to return at a later to continue the investigation.



During the facility tour with Executive Director Terrill at 12:08 pm LPA observed paint and painter's acrylic latex caulk in an unlocked business office.

During the facility tour with Executive Director Terrill at 12:12 pm LPA observed fragrance mist and body lotion in an unlocked staff break room accessible to residents.

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

Civil penalties issued in the amount of $250.00.

Exit interview was conducted, today's reports, civil penalty and appeal rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2022
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 08/08/2022 05:46 PM - It Cannot Be Edited


Created By: Joann Rosales On 08/08/2022 at 05:10 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: 08/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2022
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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Staff locked business office door during facility visit and placed fragrance mist and body lotion in an inaccessible location during facility visit. Administrator stated that they will provide documentation of scheduled staff training regarding regulation 87705(f)(2) to CCL by 8/9/22.
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Based on LPA's observations, the licensee did not comply with the section cited above as toxic items were observed accessible to residents which poses an immediate health 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: 08/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022


LIC809 (FAS) - (06/04)
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