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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850111
Report Date: 08/30/2024
Date Signed: 04/17/2025 02:16:09 PM

Document Has Been Signed on 04/17/2025 02:16 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:LEXINGTON ASSISTED LIVINGFACILITY NUMBER:
565850111
ADMINISTRATOR/
DIRECTOR:		SANJUANA JOANNA ENRIQUEZFACILITY TYPE:
740
ADDRESS:5440 RALSTON STTELEPHONE:
(805) 644-6710
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 125CENSUS: 56DATE:
08/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:09 AM
MET WITH:Martha BishopTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
NARRATIVE
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THIS IS AN AMENDED REPORT

Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management-Incident visit due to deficiencies observed in the course of a complaint investigation (complaint control number 29-AS-20240829092756). LPA met with Administrator Jill Morris Chapman and explained the reason for the amended report.

Resident (1) had a medical emergency on or about 8/13/2024. Staff called for emergency services and R1 was taken to the hospital. On or about 8/20/2024, R1 passed away at the hospital.

Community Care Licensing (CCL) did not receive an incident report for R1's medical emergency.

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

Exit interview conducted. Report and appeal rights were reviewed and issued.
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Teresa Camara
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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 08/30/2024 01:10 PM - It Cannot Be Edited


Created By: Teresa Camara On 08/30/2024 at 10:51 AM
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: 08/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
09/06/2024
Section Cited
CCR
87211(a)(1)(A)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency...(1) A written report... within seven days of the occurrence... (A) Death of any resident from any cause regardless of where the death occurred...
This requirement was not met as evidienced by:
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Licensee will review reporting requirements and provide CCL with a written statement of understanding. Licensee will also submit the death report for R1. The written statement and death report are due on or before 9/6/2024.
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Based on record review, the licensee did not comply with the section cited above as CCL did not receive a death report regarding R1's passing on or about 8/20/2024, which poses a potential health, safety, or personal rights risks to residents in care.
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Request Denied
Type B
09/06/2024
Section Cited
CCR87211(a)(1)(D)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency...(1) A written report... within seven days of the occurrence...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by:
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Licensee will review reporting requirements and provide CCL with a written statement of understanding. Licensee will also submit the death report for R1. The written statement and incident report are due on or before 9/6/2024.
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Based on record review, the licensee did not comply with the section cited above as CCL did not receive an incident report when R1 suffered a medical emergency on or about 8/13/2024, which poses a potential health, safety, or personal rights risks 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:Desaree Perera
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
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