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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850111
Report Date: 01/21/2025
Date Signed: 01/21/2025 04:27:15 PM

Document Has Been Signed on 01/21/2025 04:27 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: 63DATE:
01/21/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Jill Morris ChapmanTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20240829092756). The purpose of the visit is to issue citations for deficiencies observed during the initial complaint investigation unrelated to the complaint. During today’s visit, LPA met with administrator Jill Morris Chapman and the reason for the visit was explained.

During the complaint investigation, the following deficiencies were observed:

The facility Clinical Director indicated the practice for new residents who arrived at the facility with medication was to centrally store the medication and manually input each medication into their MAR (Medication Assistance Record) system. However, the physical medication was not cross-referenced with the LIC602 Physician Report medication list. The Clinical Director was unable to confirm R1’s medication list was cross referenced with the centrally stored medication R1 arrived with to ensure all of R1’s prescribed medication was accounted for and available. This caused R1 to not receive one of the seizure medications for 10-days, which resulted in a seizure and hospitalization.

A review of R1’s Physician Report revealed the report was not complete as the physician’s signature was missing.

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: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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 01/21/2025 04:27 PM - It Cannot Be Edited


Created By: Teresa Camara On 01/21/2025 at 02:47 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: 01/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2025
Section Cited
CCR
87465(j)

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Incidental Medical and Dental Care
(j) In all facilities licensed for 16 persons or more, one or more employees shall be designated…for assisting residents as needed with self-administration of medications... This requirement is not met as evidenced by:
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The licensee will submit the policies and procedures regarding medication audits and reconciliation in order to ensure new residents and existing residents receive all medication as prescribed. Submit proof to CCL by 1/29/2025.
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Based on record review, the licensee did not comply with the section cited above. R1’s medication was not cross referenced with the prescribed medication list which caused R1 to not receive one of the seizure medications for 10 days, which resulted in a seizure and hospitalization, which posed an immediate health and safety risk to residents in care.
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Type B
01/29/2025
Section Cited
CCR87458(a)

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87458(a) Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in
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The licensee will submit a plan how you will ensure resident documents are complete, including signatures and dates. Submit proof to CCL by 1/29/2025.
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the resident's record.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. R1’s medical assessment was missing physician signature, which posed 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.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
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