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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850111
Report Date: 11/20/2024
Date Signed: 11/20/2024 04:29:12 PM

Document Has Been Signed on 11/20/2024 04:29 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:		JILL MORRIS CHAPMANFACILITY TYPE:
740
ADDRESS:5440 RALSTON STTELEPHONE:
(805) 644-6710
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 125CENSUS: 60DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Jill Morris ChapmanTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted a required annual visit. LPA was greeted by the receptionist at 9:20 a.m. LPA met with the administrator Jill Morris Chapman and explained the reason for the visit. LPA requested documents for review.

At 10:47 a.m. LPA along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted:

KITCHEN: LPA inspected the kitchen/food service area. Knives are stored and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food as well as an emergency supply of food and water kept in supply rooms on the third floor. Refrigerator and food pantry were checked for proper labels and expiration dates.

COMMON AREAS: Furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. The fire extinguishers were fully charged and were last serviced November 2024. LPA observed required postings throughout the common space. LPA observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility has a fenced in pool in the courtyard that has two locked gates. There was patio furniture and shade for residents.

(Report Continued on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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 11/20/2024 04:29 PM - It Cannot Be Edited


Created By: Teresa Camara On 11/20/2024 at 03:35 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: 11/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of three residents' medications reviewed and missing the medication dose start date, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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Licensee will conduct training with medication technicians to ensure the centrally stored medication and destruction record (CSMDR) is being completed in full, including the start dates for all medications. Evidence of training will be submitted to CCL on or before 11/27/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/20/2024 04:29 PM - It Cannot Be Edited


Created By: Teresa Camara On 11/20/2024 at 03:35 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: 11/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one out of one residents' bathroom faucets tested for hot water temperature which measured 121.6 degrees F, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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LIcensee will adjust the hot water temperature and check a room on each of the three floors for one week to ensure the hot water temperature is in compliance. Licensee will provide the readings to CCL by 11/27/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 565850111
VISIT DATE: 11/20/2024
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(Report Continued from LIC 809...)

BEDROOMS: LPA inspected fourteen (14) resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. LPA observed a sufficient supply of towels and linens. Each room has a combination smoke detector and carbon monoxide detector, eleven (11) were tested and were operable at the time of the visit.

RESTROOMS: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water temperature was measured at 10:51 a.m. at 121.6 degrees Fahrenheit in a memory care unit. The plant manager explained the hot water heaters are shared with the adjoining skilled nursing facility (SNF) and the water heaters are located on the SNF's property. The plant manager stated he would work with the SNF plant manager to ensure the water temperature for all floors of this facility are within the regulatory requirement of 105 - 120 degrees Fahrenheit.

RECORDS: LPA reviewed five (5) resident records; all records were complete. LPA reviewed five (5) personnel records; all records were complete.

LPA reviewed the last fire suppression system inspection which was just completed on 11/13/2024. The report stated the facility needs to replace some of the sprinkler heads due to visible rust. There was also a pressure control valve that required repair. The facility plant manager is working with the inspection company to obtain a bid for the repairs. He was expecting the bid today and would be following up with them. He stated once they get the bid and the work is approved by the facility's corporate office, the repairs should only take one day to complete. LPA reviewed the facility emergency disaster plan which was just reviewed for any needed updates on 7/19/2024. The facility conducts monthly evacuation drills. Each month the drills are conducted during a different shift in order to meet quarterly training requirements. LPA obtained a copy of the facility's current certificate of liability insurance.

(Report Continued on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 565850111
VISIT DATE: 11/20/2024
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(Report Continued from LIC 809C...)

MEDICATIONS: LPA reviewed medications at 2:51 p.m. Medications are centrally stored in the medication room. Medications are labeled and checked for expiration dates. LPA observed the centrally stored medication and destruction record (CSMDR) was lacking the medication start date for resident 1 (R1). LPA observed the medication start dates on other CSMDRs for other residents were also missing. The medication technician explained they have started a new system where they put a sticker on the bubble pack or bottle cap indicating the start date so they can go back to complete the start dates on the CSMDRs. However, R1's bubble packs were missing those stickers, did not indicate the start date, nor were R1's bubble pack medications on cycle (meaning starting at the first of the month). Therefore, LPA was unable to determine if R1's medications were being given as prescribed.

INTERVIEWS: LPA interviewed three (3) residents and three (3) staff; no concerns were noted.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
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