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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850111
Report Date: 01/06/2025
Date Signed: 01/07/2025 08:52:22 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/20/2023 and conducted by Evaluator Erika Miller
COMPLAINT CONTROL NUMBER: 29-AS-20230620161947
FACILITY NAME:LEXINGTON ASSISTED LIVINGFACILITY NUMBER:
565850111
ADMINISTRATOR:ERIC TERRILLFACILITY TYPE:
740
ADDRESS:5440 RALSTON STTELEPHONE:
(805) 644-6710
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:125CENSUS: 64DATE:
01/06/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jill Morris Chapman, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Lack of supervision resulting in injury.
INVESTIGATION FINDINGS:
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THIS IS AN AMENDED REPORT

Licensing Program Analyst (LPA) Erika Miller (Miller) conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Jill Morris Chapman, Administrator and explained the purpose of the visit. Previously, Licensing Program Analyst (LPA) Christine Yee conducted an unannounced initial complaint visit to investigate the above allegations and met with Ashley Villarreal, Community Liaison. LPA Yee conducted an interview with Ashley Villarreal and collected relevant documentation.

Allegation: It was alleged that there was a lack of supervision resulting in injury. Resident 1 (R1) was admitted to facility on 6/13/23 and admitted to hospice on 6/14/23. Based on the 6/16/23 incident report created by facility, R1 was found on the floor of their room at 8:30 a.m. and subsequently transported to hospital per family member request. R1 moved out of the facility on 6/19/23. Administrator advised that R1 did not return to Faciilty, as such hospital discharge paperwork was not provided. (Contintued on 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20230620161947
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/06/2025
NARRATIVE
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As of 12/30/24, R1’s family could not be contacted as the phone number was no longer in service, as such R1 could not be contacted. Administrator at the time of the incident is no longer employed at the facility and current administrator has no knowledge of the incident that occurred on 6/16/23.

LPA Miller reviewed 6/12/23 LIC 602, that stated R1 had end stage dementia and no capacity for self-care. R1 is non-ambulatory based on both physical and mental condition. LPA reviewed R1’s Needs and Services Plan that indicated R1 required one person assistance with oral, skin and daily grooming and requires a reminder assistance with dressing and undressing. Based on the information available, there was no indication R1 required additional supervision that was not provided and that led to the injury.

Administrator, Jill Morris Chapman stated that that on 6/15/23, there were 14 Memory Care residents and 68 independent and assisted living residents. Based on the records, on 6/15/23 there was 1 staff working NOC shift in Memory Care and on 6/16/23 there were 2 staff working AM shift Memory Care. Administrator stated that facility currently has 12 residents in memory care and 1 NOC staff is sufficient, as clients are settled down between the hours of 10:00 p.m. and 6:00 a.m.

Although, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time.


An Exit interview conducted and a copy of this report an appeal rights were issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/20/2023 and conducted by Evaluator Erika Miller
COMPLAINT CONTROL NUMBER: 29-AS-20230620161947

FACILITY NAME:LEXINGTON ASSISTED LIVINGFACILITY NUMBER:
565850111
ADMINISTRATOR:ERIC TERRILLFACILITY TYPE:
740
ADDRESS:5440 RALSTON STTELEPHONE:
(805) 644-6710
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:125CENSUS: 644DATE:
01/06/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jill Morris Chapman, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Facility did not notify resident's responsible party of an incident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erika Miller (Miller) conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Jill Morris Chapman, Administrator and explained the purpose of the visit. Previously, Licensing Program Analyst (LPA) Christine Yee conducted an unannounced initial complaint visit to investigate the above allegations and met with Ashley Villarreal, Community Liaison. LPA Yee conducted an interview with Ashley Villarreal and collected relevant documentation.

On the allegation that Facility did not notify resident's responsible party of an incident. It was alleged that Resident 1 (R1) suffered an injury from a fall, but facility never informed the resident's family member and they only learned of the incident from an outside agency, Mission Hospice.

(Contined on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20230620161947
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/06/2025
NARRATIVE
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LPA reviewed 6/16/23, Incident Report, that indicates R1 was observed on floor at 8:30 a.m. The document states, “Hospice Notified” and R1 taken to Ventura County Medical Center. It is unclear who prepared the report.

It is relevant to note that there is no record that this document was submitted to Community Care Licensing. It appears that Mission Hospice was notified. There is no evidence to support that family member was notified as required by regulations.

Based on LPAs record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, are being cited on the attached LIC 9099D.

An Exit interview conducted and a copy of this report an appeal rights were issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20230620161947
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2025
Section Cited
CCR
87211(a)
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Each licensee shall furnish to ... licensing ...such reports as the Department may require, (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence......
This requirement is not met as evidenced by:
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Administrator agrees to ensure that staff review reporting requirements and send statement of understanding to LPA Erika Miller.
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Based on records review, the licensee did not comply with the section cited above when staff did not notify person responsible for resident within seven days of the fall, which poses a potential health and safety risk 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5