Inspection Report Summary
Most inspections found deficiencies related primarily to medication management, resident care and supervision, and safety issues such as unsecured toxic substances and inadequate staffing. Several serious incidents occurred, including failure to administer prescribed seizure medication leading to hospitalization and death of a resident, multiple fractures from falls due to lack of supervision, and fines totaling over $20,000 for these and other violations. Many complaint investigations were substantiated, particularly those involving neglect in medication administration and personal care, while others were unsubstantiated. The most recent report from October 31, 2025, was clean with no deficiencies cited, indicating some improvement after prior issues. Overall, the facility has shown a pattern of serious care and safety concerns in past years but recent inspections suggest corrective actions have been made.
Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 63
Capacity: 125
Deficiencies: 0
Oct 31, 2025
Visit Reason
The inspection was a required annual unannounced visit to evaluate compliance with licensing requirements and to investigate a recent self-reported incident involving a staff member and a resident.
Findings
The facility was found to be generally in compliance with health and safety regulations, with clean and well-maintained resident rooms, restrooms, common areas, and kitchen. No citations were issued during this visit. The medication review was deferred to a continuation visit due to time constraints.
Report Facts
Rooms inspected: 10
Resident records reviewed: 5
Personnel records reviewed: 5
Staff interviewed: 4
Residents interviewed: 3
Hot water temperature range: 106.2-110.2
Fire extinguisher last serviced: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SanJuana Joanna Enriquez | Administrator | Facility Administrator present during inspection and involved in entrance interview and facility tour |
| Kelly Dulek | Licensing Program Analyst | Conducted the annual inspection and interviews |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 125
Deficiencies: 1
Aug 21, 2025
Visit Reason
The inspection was conducted as a follow-up on a substantiated complaint investigation regarding neglect and lack of care and supervision involving a resident who required medical attention due to staff's failure to dispense prescribed medication.
Findings
The Department found that the facility failed to administer prescribed medication to Resident #1, resulting in a seizure requiring medical attention and hospitalization. The licensee was cited for violation of California Code of Regulations 87465(a)(4) and assessed civil penalties totaling $10,000, with $9,500 issued on this visit due to a prior penalty.
Complaint Details
The complaint investigation was substantiated. The allegation involved neglect and lack of care and supervision due to failure to dispense prescribed medication, causing serious bodily injury to Resident #1.
Deficiencies (1)
| Description |
|---|
| Failure to dispense prescribed medication to Resident #1 resulting in medical attention and hospitalization. |
Report Facts
Civil penalty amount: 10000
Civil penalty amount previously issued: 500
Additional civil penalty amount: 500
Civil penalty amount issued on 08/21/2025: 9500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SanJuana Enriquez | Acting Administrator | Met with licensing staff during inspection and acknowledged appeal rights |
| David Rivas | Clinical Director, RN | Met with licensing staff during inspection |
| Ann Margaret Zavela | Market Leader, RN | Met with licensing staff during inspection |
| Monica Guardian | Interim Executive Director | Met with licensing staff during inspection |
| Roanne de los Reyes | Clinical Market Leader | Met with licensing staff during inspection |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 125
Deficiencies: 0
Aug 21, 2025
Visit Reason
The inspection was conducted as an Informal Conference to discuss complaint investigation 29-AS-20240829092756 regarding medication administration and a self-reported altercation between a resident and staff.
Findings
The investigation concluded that Resident #1 was not given seizure medication for approximately 10 days, resulting in seizures and eventual death, though the facility was not found liable. An unkempt room allegation was unsubstantiated. Additionally, a verbal altercation incident on 08/05/2025 was reported, with staff training planned to address concerns.
Complaint Details
Complaint investigation 29-AS-20240829092756 involved allegations of questionable death, medications not given as prescribed, and an unkempt resident room. The medication allegation was substantiated as Resident #1 did not receive seizure medication for about 10 days, leading to seizures and death. The unkempt room allegation was unsubstantiated.
Report Facts
Facility capacity: 125
Current census: 69
Complaint investigation number: 29-AS-20240829092756
Date of incident: 08/05/2025 verbal altercation incident date
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SanJuana Enriquez | Administrator | Present at Informal Conference and involved in discussion of complaint and incident |
| David Rivas | Clinical Director | Explained situation regarding resident and staff altercation and steps taken |
| Kristin Heffernan | Licensing Program Manager | Attended Informal Conference and signed report |
| Kelly Dulek | Licensing Program Analyst | Attended Informal Conference and signed report |
Inspection Report
Census: 68
Capacity: 125
Deficiencies: 0
Jul 17, 2025
Visit Reason
The visit was a case management legal/non-compliance inspection conducted by the Licensing Program Analyst to review medication documentation and compliance.
Findings
A medication audit was conducted for five residents, including on-cycle, not on-cycle, and PRN medications with narcotics. All medications were correctly documented with physicians' orders. No citations were issued.
Report Facts
Residents' medications audited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joanna Enriquez | Interim Executive Director | Met with Licensing Program Analyst during the inspection |
| David Rivas | Clinical Director, RN | Met with Licensing Program Analyst during the inspection |
| Teresa Camara | Licensing Program Analyst | Conducted the case management legal/non-compliance visit and medication audit |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 125
Deficiencies: 0
Jul 17, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that facility staff did not assist a resident with hygiene and medical care as needed, and that the facility maintained a resident beyond their level of care.
Findings
The investigation found that the resident had a healing wound not related to pressure injury and was receiving appropriate wound care including home health services. The resident occasionally refused shower assistance but medical needs were addressed, and attempts were made to secure specialist care. The allegations were deemed unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint involved allegations of inadequate assistance with hygiene and medical care, and maintaining a resident beyond their level of care. After document review, interviews, and observations, all allegations were found unsubstantiated.
Report Facts
Capacity: 125
Census: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation |
| Joanna Enriques | Interim Executive Director | Met with Licensing Program Analyst during investigation |
| Davi Rivas | Clinical Director, RN | Interviewed during investigation regarding resident care |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 125
Deficiencies: 0
Jul 17, 2025
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that staff did not provide adequate supervision resulting in a resident leaving the facility.
Findings
The investigation found that the resident was confused about the whereabouts of their daughter but did not leave the facility unsupervised. The resident required wheelchair use due to medical recovery but did not have a cognitive disability. Based on documents, interviews, and observations, the allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged inadequate supervision leading to a resident leaving the facility. The investigation included interviews with the resident, clinical director, and review of documents and video. The allegation was found unsubstantiated.
Report Facts
Capacity: 125
Census: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation visit |
| Joanna Enriquez | Interim Executive Director | Met with Licensing Program Analyst during investigation |
| Davi Rivas | Clinical Director, RN | Interviewed during the investigation |
Inspection Report
Census: 67
Capacity: 125
Deficiencies: 0
Jul 10, 2025
Visit Reason
The inspection visit was a case management legal/non-compliance visit conducted to review the facility's compliance with licensing requirements.
Findings
No citations were issued during the visit. A medication audit was started but not completed, with plans to return at a later date to finish the audit. The facility had a sufficient supply of food and the visit included a tour of selected areas including the memory care unit and kitchen.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joanna Enriquez | Interim Executive Director | Met with Licensing Program Analyst during the inspection visit. |
| David Rivas | Clinical Director, RN | Met with Licensing Program Analyst during the inspection visit. |
| Teresa Camara | Licensing Program Analyst | Conducted the case management legal/non-compliance visit. |
Inspection Report
Census: 67
Capacity: 125
Deficiencies: 1
Jun 26, 2025
Visit Reason
The visit was a case management legal/non-compliance inspection focused on auditing medications at Lexington Assisted Living Facility.
Findings
The inspection found that the centrally stored medication and destruction record was missing start dates on nearly all medications for Resident 1. Medications were not properly documented or administered as prescribed, posing an immediate health and safety risk. An immediate civil penalty of $1,000 was assessed for a repeat violation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to comply with medication administration and documentation requirements, including missing start dates and improper medication administration for Resident 1. | Type A |
Report Facts
Civil penalty amount: 1000
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Rivas | Clinical Director, RN | Met during inspection and involved in medication audit |
| Teresa Camara | Licensing Program Analyst | Conducted the case management legal/non-compliance visit |
| Desaree Perera | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 68
Capacity: 125
Deficiencies: 1
Jun 13, 2025
Visit Reason
The inspection was an unannounced follow-up visit on June 13, 2025, to review a substantiated allegation from a prior complaint investigation regarding a resident who sustained multiple fractures while in care.
Findings
The Department determined that a civil penalty is warranted for serious bodily injury due to the facility's failure to provide proper care and supervision, resulting in multiple fractures from multiple falls. A civil penalty of $9,500 was issued after accounting for a prior $500 penalty.
Complaint Details
The visit was a follow-up to a substantiated complaint investigation (complaint control number 29-AS-20210226132843) regarding Resident #1 sustaining multiple fractures while in care. The complaint was substantiated and resulted in citations and civil penalties.
Deficiencies (1)
| Description |
|---|
| Violation of Health and Safety Code §1569.312 Basic Services Requirements related to failure to provide proper care and supervision resulting in multiple fractures. |
Report Facts
Civil penalty amount: 9500
Civil penalty amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Rivas | Clinical Director, RN | Met during inspection and acknowledged receipt of appeal rights related to the findings. |
| Teresa Camara | Licensing Program Analyst | Conducted the unannounced follow-up inspection. |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 125
Deficiencies: 0
Apr 17, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2025-01-08 regarding allegations about resident care and facility maintenance.
Findings
The investigation found the allegations to be unsubstantiated after discussions with the resident and facility staff clarified the issues, and the resident chose not to pursue the complaint.
Complaint Details
The complaint involved allegations that staff had not reassessed a resident for change in level of care, and that staff did not ensure facility carpeting was clean or the elevator was maintained. The complaint was deemed unsubstantiated after the resident stated the complaint was a mistake based on a misunderstanding.
Report Facts
Capacity: 125
Census: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jill Morris Chapman | Administrator | Facility administrator met with the investigator and was involved in clarifying the complaint |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 125
Deficiencies: 0
Apr 17, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2025-01-16 alleging that staff does not ensure residents' care needs are being met.
Findings
The investigation found that the complaint was a misunderstanding, as Resident 1 clarified the issue after meeting with the Administrator and Long Term Care Ombudsman, and does not wish to pursue the complaint. The allegation was deemed unsubstantiated.
Complaint Details
The complaint was unsubstantiated after investigation. Resident 1 stated the complaint was a mistake based on a misunderstanding and chose not to pursue it further.
Report Facts
Complaint Control Number: 29-AS-20250116105947
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Jill Morris Chapman | Administrator | Met with Licensing Program Analyst and involved in investigation. |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 125
Deficiencies: 0
Mar 20, 2025
Visit Reason
An unannounced complaint investigation visit was conducted regarding allegations that facility staff locked a resident in their bedroom and did not ensure the resident's records were complete.
Findings
Both allegations were deemed unsubstantiated. The resident's bedroom door was locked for safety and could be opened from the inside. The resident's POLST document was incomplete due to lack of decision-making capacity and absence of a responsible party, despite efforts by the administrator to obtain a public guardian.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included locking a resident in their bedroom and incomplete resident records related to hospice care and POLST documentation.
Report Facts
Capacity: 125
Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jill Morris Chapman | Administrator | Met with Licensing Program Analyst and involved in investigation |
| Desaree Perera | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 125
Deficiencies: 2
Jan 21, 2025
Visit Reason
The visit was a Case Management - Deficiencies inspection conducted in conjunction with a complaint investigation to issue citations for deficiencies observed during the initial complaint investigation unrelated to the complaint.
Findings
Deficiencies were found related to medication management where a resident (R1) did not receive a prescribed seizure medication for 10 days, resulting in a seizure and hospitalization. Additionally, R1's Physician Report was incomplete due to a missing physician's signature.
Complaint Details
The visit was conducted in conjunction with a complaint investigation (Complaint Control # 29-AS-20240829092756).
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| R1’s medication was not cross referenced with the prescribed medication list, causing R1 to not receive one of the seizure medications for 10 days, resulting in a seizure and hospitalization. | Type A |
| R1’s medical assessment was missing physician signature. | Type B |
Report Facts
Plan of Correction Due Date: Jan 29, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Morris Chapman | Administrator | Met with during the inspection and discussed visit reason |
| Teresa Camara | Licensing Program Analyst | Conducted the inspection and signed the report |
| Desaree Perera | Licensing Program Manager | Named as supervisor and licensing program manager |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 125
Deficiencies: 1
Jan 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of neglect/lack of care and supervision related to Resident #1 (R1) not receiving prescribed seizure medication, resulting in medical attention, and a separate allegation of questionable death and unkempt room conditions.
Findings
The investigation substantiated that staff failed to administer one of R1's prescribed seizure medications, leading to a seizure and medical attention, resulting in a $1,000 immediate civil penalty for repeat violation. The allegation that R1 sustained multiple seizures and subsequently expired due to staff neglect was unsubstantiated. The allegation that R1's room was left unkempt was also unsubstantiated based on observations and staff interviews.
Complaint Details
The complaint was substantiated regarding neglect/lack of care and supervision due to failure to dispense prescribed seizure medication to Resident #1, causing a seizure and medical attention. The allegation of questionable death due to staff neglect was unsubstantiated. The allegation that the resident's room was left unkempt was also unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff did not dispense prescribed medication to Resident #1, resulting in a seizure and required medical attention, posing an immediate health and safety risk. | Type A |
Report Facts
Immediate civil penalty: 1000
Capacity: 125
Census: 63
Plan of Correction Due Date: Jan 29, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Jill Morris Chapman | Administrator | Met with Licensing Program Analyst during investigation. |
| Sanjuana Joanna Enriquez | Administrator | Named as facility administrator in report header. |
| Sonia Torre | Investigator | Assigned to complaint investigation branch and conducted interviews. |
| Desaree Perera | Licensing Program Manager | Oversaw licensing program and signed report. |
| Dr. Duma | Primary Neurosurgeon | Interviewed regarding Resident #1's death and medical condition. |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 125
Deficiencies: 1
Jan 6, 2025
Visit Reason
The inspection was conducted as a complaint investigation following allegations of lack of supervision resulting in injury and failure to notify the resident's responsible party of an incident.
Findings
The allegation of lack of supervision resulting in injury was found to be unsubstantiated due to insufficient evidence. However, the allegation that the facility failed to notify the resident's responsible party of the incident was substantiated, citing a violation of California Code of Regulations requiring notification within seven days.
Complaint Details
The complaint investigation was triggered by allegations that the facility did not provide adequate supervision resulting in injury to Resident 1 (R1), and that the facility failed to notify the resident's responsible party of the incident. The lack of supervision allegation was unsubstantiated, but the failure to notify allegation was substantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify person responsible for resident within seven days of the fall, posing a potential health and safety risk. | Type B |
Report Facts
Memory Care residents: 14
Independent and assisted living residents: 68
Staff working NOC shift in Memory Care: 1
Staff working AM shift in Memory Care: 2
Residents in Memory Care: 12
Census: 64
Total Capacity: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erika Miller | Licensing Program Analyst | Conducted the complaint investigation and issued final findings |
| Jill Morris Chapman | Administrator | Facility administrator met with Licensing Program Analyst during investigation and provided information |
| Christine Yee | Licensing Program Analyst | Conducted initial unannounced complaint visit |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 125
Deficiencies: 0
Dec 20, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff were not meeting the resident's medical needs and not administering medications as prescribed.
Findings
The investigation found insufficient evidence to support the allegations. Staff were found to assist residents when called, communicate with physicians, and administer medications as prescribed. The allegations were deemed unsubstantiated.
Complaint Details
The complaint alleged that staff were not meeting the medical needs of Resident #1, who had bed sores and sustained falls, and that staff did not administer prescribed medications, specifically insulin. The investigation included interviews, resident file reviews, medication audits, and communication with the resident's primary care physician. The allegations were unsubstantiated due to lack of evidence.
Report Facts
Capacity: 125
Census: 66
Complaint Control Number: 29-AS-20240418165616
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation visits and authored the report |
| Jill Morris Chapman | Executive Director | Met with Licensing Program Analyst during the investigation |
| Sanjuana Joanna Enriquez | Administrator | Facility administrator named in the report |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 60
Capacity: 125
Deficiencies: 2
Nov 20, 2024
Visit Reason
Licensing Program Analyst Teresa Camara conducted a required annual unannounced visit to evaluate compliance with Title 22 Regulations and ensure health and safety standards at Lexington Assisted Living Facility.
Findings
The facility was generally in good condition with no health or safety hazards noted in physical plant areas. However, two deficiencies were cited: missing medication dose start dates in centrally stored medication records, and hot water temperature exceeding regulatory limits in one resident bathroom. Plans of correction were submitted with due dates.
Deficiencies (2)
| Description |
|---|
| Missing medication dose start date in centrally stored medication and destruction record for one out of three residents reviewed. |
| Hot water temperature in one resident bathroom measured 121.6 degrees Fahrenheit, exceeding the regulatory maximum of 120 degrees. |
Report Facts
Residents' medication records reviewed: 3
Resident bedrooms inspected: 14
Resident records reviewed: 5
Personnel records reviewed: 5
Fire suppression system inspection date: Nov 13, 2024
Hot water temperature measured: 121.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Morris Chapman | Administrator | Met with Licensing Program Analyst during inspection |
| Teresa Camara | Licensing Program Analyst | Conducted the annual inspection and authored the report |
| Desaree Perera | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 125
Deficiencies: 0
Oct 11, 2024
Visit Reason
The visit was conducted as a Case Management - Incident investigation regarding a self-reported suspicion of elder financial abuse by a staff member at the facility.
Findings
The Licensing Program Analyst conducted interviews and collected pertinent documents. Further investigation is necessary.
Complaint Details
The visit was triggered by a self-reported suspicion of elder financial abuse by a staff member. Further investigation is necessary.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Morris Chapman | Administrator/Executive Director | Met with Licensing Program Analyst during the investigation and interview. |
| Teresa Camara | Licensing Program Analyst | Conducted the Case Management - Incident visit and interview. |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 125
Deficiencies: 0
Sep 30, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2023-03-01 concerning medical attention, nutrition, incontinence care, and room conditions at Lexington Assisted Living Facility.
Findings
After thorough investigation including interviews, file reviews, and observations, all allegations were deemed unsubstantiated due to insufficient evidence or resolution of issues such as a prior plumbing problem. No deficiencies were cited during the investigation.
Complaint Details
The complaint investigation addressed allegations that staff did not seek medical attention for residents, did not provide nutritious meals, did not aid residents with incontinence needs, and did not ensure residents' rooms were free from malodorous conditions. The investigation found these allegations unsubstantiated based on interviews, file reviews, observations, and evidence of prior resolution of issues.
Report Facts
Capacity: 125
Census: 57
Number of residents interviewed: 8
Number of residents interviewed: 9
Number of residents interviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Jill Morris Chapman | Executive Director | Met with Licensing Program Analyst during investigation and provided information |
| Kasandra Lopez | Licensing Program Manager | Oversaw the complaint investigation report |
| Eric Terrill | Administrator | Facility administrator mentioned in report header |
| Wellness Director | Interviewed regarding medical attention protocols for residents |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 125
Deficiencies: 2
Aug 30, 2024
Visit Reason
Licensing Program Analyst Teresa Camara conducted a Case Management-Incident visit due to deficiencies observed during a complaint investigation related to failure to report a resident's medical emergency and death.
Findings
The facility failed to submit required incident and death reports to Community Care Licensing for a resident's medical emergency on 8/13/2024 and subsequent death on 8/20/2024, posing potential health, safety, or personal rights risks to residents.
Complaint Details
The visit was triggered by a complaint investigation (complaint control number 29-AS-20240829092756). The complaint was substantiated as deficiencies were found related to failure to report incidents as required.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to submit a death report regarding resident's passing on or about 8/20/2024. | Type B |
| Failure to submit an incident report when resident suffered a medical emergency on or about 8/13/2024. | Type B |
Report Facts
Census: 56
Total Capacity: 125
Plan of Correction Due Date: Sep 6, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the Case Management-Incident visit and authored the report |
| Sanjuana Joanna Enriquez | Administrator/Director | Facility administrator listed in report header |
| Jill Morris Chapman | Met with Licensing Program Analyst during amended report explanation |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 125
Deficiencies: 2
Aug 22, 2024
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations received on 2023-02-01 regarding staff handling of residents, call light response times, staff communication, and food quality at Lexington Assisted Living Facility.
Findings
The investigation found insufficient evidence to substantiate most allegations including inappropriate handling of a resident, untimely call light responses, inappropriate speech by staff, communication barriers, and inadequate food quantity and quality. However, two allegations were substantiated: staff did not assist a resident with self-administration of medications as prescribed during the first days after move-in, and staff did not provide shower assistance as required during the resident's first week at the facility.
Complaint Details
The complaint investigation was triggered by allegations including inappropriate handling of a resident, untimely response to call lights, inappropriate speech by staff, communication issues, inadequate food, failure to assist with medication administration, and failure to provide shower assistance. Most allegations were unsubstantiated except for failure to assist with medications and showering, which were substantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee did not assist resident with self-administered medications as needed, with medications not documented as administered until two days after move-in, posing a potential health and safety risk. | Type B |
| Resident did not receive required assistance with bathing twice weekly, missing showers for 8 days following move-in, posing a potential health and personal rights risk. | Type B |
Report Facts
Capacity: 125
Census: 57
Deficiencies cited: 2
Days without shower: 8
Date of complaint received: Feb 1, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Eric Terrill | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 125
Deficiencies: 1
May 22, 2024
Visit Reason
The visit was an unannounced Case Management – Deficiency visit conducted in conjunction with a complaint investigation to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.
Findings
The facility was unable to provide all of Resident #1's medication records, as they archived all records and marked medications as discontinued when residents move out or expire, posing a potential health and safety risk to residents in care. A citation was issued.
Complaint Details
The visit was conducted in conjunction with complaint visit CC #29-AS-20231020083938. The deficiencies cited were observed during the complaint investigation but were not related to the complaint itself.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain a separate, complete, and current record for each resident that is readily available to facility staff and licensing agency staff, including retaining original records or photographic reproductions for a minimum of three years following termination of service. | Type B |
Report Facts
Capacity: 125
Census: 56
Plan of Correction Due Date: May 31, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Morris Chapman | Executive Director | Met with Licensing Program Analyst during the inspection |
| Martha Arroyo | Licensing Program Analyst | Conducted the unannounced Case Management – Deficiency visit |
| Desaree Perera | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 125
Deficiencies: 2
May 22, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 10/20/2023 regarding neglect and lack of care and supervision at Lexington Assisted Living Facility, specifically concerning failure to provide medication to Resident #1 (R1), failure to attend to R1's request for assistance in a timely manner, malfunctioning resident pendant, and ineffective communication with an authorized representative.
Findings
The investigation found insufficient evidence to substantiate allegations related to failure to provide medication contributing to R1's death, malfunctioning pendants, and ineffective communication with authorized representatives. However, the allegations that facility staff failed to provide certain prescribed medications (Buprenorphine, Ticagrelor, Aspirin) to R1 and failed to respond to R1's requests for assistance in a timely manner were substantiated. Deficiencies were cited related to medication administration and staffing levels impacting resident care.
Complaint Details
The complaint was received on 10/20/2023 alleging neglect and lack of care and supervision, including failure to provide medication to Resident #1 (R1) which allegedly contributed to R1's death, failure to attend to R1's requests timely, malfunctioning pendants, and ineffective communication with authorized representatives. The investigation concluded the medication and pendant allegations related to death and pendant malfunction were unsubstantiated, but the failure to provide prescribed medications and timely response to assistance requests were substantiated.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility staff failed to provide R1’s Buprenorphine, Ticagrelor, and aspirin as prescribed, posing an immediate health and safety risk. | Type A |
| Facility staff failed to respond to R1 in a timely manner, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 125
Census: 56
Deficiency count: 2
Medication delivery dates: Jun 8, 2023
Investigation visit date: May 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted complaint investigation and delivered final findings |
| Desaree Perera | Licensing Program Manager | Oversaw complaint investigation |
| Eric Terrill | Administrator | Facility administrator named in report |
| Jill Morris Chapman | Executive Director | Met with Licensing Program Analyst during investigation visit |
| Laarni Santiago | Investigator | Assigned investigator who conducted interviews and evidence review |
Inspection Report
Annual Inspection
Census: 77
Capacity: 125
Deficiencies: 1
Nov 6, 2023
Visit Reason
The inspection was an unannounced required annual visit to evaluate compliance with Title 22 Regulations and ensure health and safety standards at Lexington Assisted Living Facility.
Findings
The facility was generally found to be in compliance with health and safety regulations, including kitchen safety, common area conditions, and proper record keeping. One deficiency was noted regarding a mismatch in the prescription number on a resident's medication bottle compared to the centrally stored medication record, which was corrected during the visit.
Deficiencies (1)
| Description |
|---|
| Resident #1’s medication prescription number on the bottle did not match that on the centrally stored medication and destruction record. |
Report Facts
Resident files reviewed: 7
Personnel files reviewed: 7
Personnel with active first aid/CPR: 1
Hot water temperature measurements: 8
Hot water temperature measurements: 2
Fire inspection date: Feb 20, 2022
Fire and earthquake drills: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Terrill | Administrator | Facility administrator named in the report header. |
| Sanjuana Enriquez | Interim Executive Director | Met with Licensing Program Analysts during the inspection. |
| Martha Arroyo | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Desaree Perera | Licensing Program Manager | Named as supervisor and licensing program manager. |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 125
Deficiencies: 1
Aug 25, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to allegations that staff failed to provide adequate food service, failed to meet resident's medical needs, and failed to meet resident's hygiene needs.
Findings
The investigation found insufficient evidence to substantiate allegations regarding inadequate food service and unmet medical needs, deeming those allegations unsubstantiated. However, the allegation that staff failed to meet resident's hygiene needs was substantiated due to lack of proper shower documentation and false recording by staff, posing a potential health and safety risk.
Complaint Details
The complaint investigation was triggered by allegations that staff failed to provide adequate food service, failed to meet resident's medical needs, and failed to meet resident's hygiene needs. The food service and medical needs allegations were unsubstantiated. The hygiene needs allegation was substantiated due to evidence of inadequate bathing and false documentation by staff.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to meet resident's hygiene needs as evidenced by lack of shower records and false documentation. | Type B |
Report Facts
Capacity: 125
Census: 82
Physical therapy sessions: 3
Plan of Correction due date: Sep 8, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation |
| Eric Terrill | Administrator | Facility administrator named in the report |
| Ashley Villareal | Family Advisor | Met with the Licensing Program Analyst during the investigation |
| Justin Ramirez | Wellness Director | Provided information about physical therapy services |
| Mayra Gutierrez | Business Manager | Participated in exit interview and report review |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 125
Deficiencies: 2
Aug 9, 2023
Visit Reason
The visit was conducted to conclude an investigation initiated after two elopement incidents involving residents leaving the facility unassisted, reported on 07/20/2023 and 07/31/2023.
Findings
The investigation found that Resident #1's change in condition was not documented or reported to the primary care physician, and Resident #2, diagnosed with dementia, left the facility unassisted due to insufficient staffing and front desk staff being on break. Deficiencies were cited related to inadequate staffing and failure to update resident reappraisals.
Complaint Details
The visit was complaint-related due to two elopement incidents: Resident #1 eloped on 07/20/2023 and Resident #2 eloped on 07/31/2023. Resident #1 does not have dementia and can leave unassisted per physician report, but staff had concerns about safety. Resident #2 has dementia and cannot leave unassisted. The complaint was substantiated with deficiencies cited.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Insufficient staff to ensure Resident #2 did not leave the facility unassisted per physician report, posing an immediate health and safety risk. | Type A |
| Failure to update Resident #1's reappraisal to reflect change of condition, posing a potential health and safety risk. | Type B |
Report Facts
Deficiencies cited: 2
Plan of Correction Due Dates: Type A deficiency due 08/10/2023, Type B deficiency due 08/23/2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Villareal | Family Advisor | Met with during visit and discussed incidents and corrective actions |
| Justin Ramirez | Wellness Director | Participated in exit interview and discussion of incidents and corrective actions |
| Eric Terrill | Administrator | Mentioned as facility administrator involved in planning corrective actions |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 125
Deficiencies: 0
Aug 9, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that the facility refused to reimburse a former resident's Power of Attorney (POA).
Findings
The investigation found that a refund check for $3,599.94 was issued and cashed by the POA, and there was no sufficient evidence to support the allegation that the facility refused reimbursement. Therefore, the complaint was deemed unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint alleged that the facility refused to reimburse a former resident's POA a total refund of $5,500, including a $3,500 community fee and a $2,000 holding fee. The investigation revealed a refund was initiated and a prorated refund was issued for room and board fees. The refund check was confirmed cashed by the POA. The allegation was unsubstantiated.
Report Facts
Refund amount: 5500
Community fee refund: 3500
Holding fee refund: 2000
Refund check amount: 3599.94
Room and board fee refund: 2100.06
Census: 83
Total capacity: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation and subsequent visit |
| Eric Terrill | Administrator | Facility administrator interviewed during investigation |
| Ashley Villareal | Family Advisor | Met with Licensing Program Analyst during visit |
| Justin Ramirez | Wellness Director | Arrived during visit and involved in investigation |
| Mayra Gutierrez | Business Manager | Provided information about refund check status |
| Joanna | Administrator | Interviewed during initial visit and provided information on refund process |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 125
Deficiencies: 2
Jul 27, 2023
Visit Reason
The visit was an unannounced complaint investigation to deliver findings related to allegations including residents being left sitting in a chair all day, inadequate care and supervision, failure to safeguard personal items, residents not dressed in their own clothing, multiple falls, failure to follow reporting requirements, and a scabies outbreak.
Findings
The investigation found the allegations that residents were left sitting all day, staff did not provide adequate care and supervision, staff did not safeguard personal items, and residents were not dressed in their own clothing to be unsubstantiated. However, the allegations that a resident sustained multiple falls, the facility had scabies, and the facility failed to follow reporting requirements were substantiated. Deficiencies were cited related to personal rights and reporting requirements.
Complaint Details
The complaint investigation was triggered by allegations received on 05/21/2021 concerning resident neglect, inadequate supervision, loss of personal items, improper clothing, multiple falls, failure to report incidents, and a scabies outbreak. The investigation was conducted through interviews, record reviews, and facility tours. The allegations regarding neglect, supervision, personal items, and clothing were unsubstantiated, while those regarding multiple falls, scabies, and reporting failures were substantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Residents shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff. The licensee did not comply as Resident #1 was not properly cared for and supervised after diagnosis of a fracture and physical condition changes. | Type A |
| A written report shall be submitted to the licensing agency within seven days of any incident threatening resident welfare, safety, or health. The licensee did not comply as the facility had a scabies outbreak in October 2020 but did not report it to CCLD until February 2021. | Type B |
Report Facts
Resident falls frequency: 1
Residents treated for scabies: 10
Plan of Correction due dates: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation and signed the report. |
| Sanjuana Enriquez | Administrator / Executive Director | Facility administrator involved in interviews during the investigation. |
| Mayra Gutierrez | Business Office Manager | Met with Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 125
Deficiencies: 0
Jul 20, 2023
Visit Reason
The visit was an unannounced Case Management - Incident inspection conducted to follow up on an elopement incident reported on 07/20/2023 involving Resident #1 who left the facility unassisted.
Findings
The facility received a report that Resident #1 had eloped and was found offsite by staff. The resident was returned to the facility, monitored, and their physician and family were notified. Staff expressed concern about the resident's ability to leave unassisted, and further investigation was deemed necessary.
Complaint Details
The visit was conducted in conjunction with an initial complaint visit (Complaint Control #29-AS-20230714150808) related to the elopement incident. Further investigation was needed prior to issuing a final licensing report.
Report Facts
Time of incident: 13
Visit start time: 15
Visit end time: 16.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joanna Enriquez | Interim Administrator | Met with Licensing Program Analyst during the visit and involved in incident response. |
| Ashley Villareal | Marketing Director | Assisted in picking up Resident #1 after elopement. |
| Justin Ramirez | Wellness Director | Conducted head-to-toe check on Resident #1 and involved in monitoring and follow-up. |
| Esther Cortez | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 125
Deficiencies: 0
Mar 15, 2023
Visit Reason
The inspection was conducted as a complaint investigation following an allegation received on 05/09/2022 that facility staff failed to keep a resident safe after an incident on 04/05/2022 involving an alleged assault in the elevator.
Findings
The investigation found insufficient evidence to substantiate the allegation that facility staff failed to keep the resident safe. Interviews and document reviews indicated the resident fell in the elevator and staff responded appropriately, with no evidence of physical aggression by other residents.
Complaint Details
The complaint alleged that resident 1 was assaulted by resident 2 in the elevator on or about 04/05/2022. The allegation was found unsubstantiated based on interviews and document review.
Report Facts
Complaint Control Number: 29-AS-20220509152612
Incident Date: 04/05/2022
Complaint Received Date: 05/09/2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted complaint investigation and interviews |
| Sanjuana Enriquez | Executive Director | Met with investigators and received report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report signature |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 125
Deficiencies: 1
Feb 21, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not following physician's orders and not answering residents' call lights timely.
Findings
The investigation substantiated that staff failed to follow physician's orders regarding medication administration for two residents, posing an immediate health and safety risk. However, the allegation that staff did not answer residents' call lights timely was unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged that staff were not following physician's orders for residents R1 and R2, specifically regarding timely administration of fentanyl patches and routine Morphine and Lorazepam medications. It also alleged staff did not answer residents' call lights timely. The fentanyl patch administration was not consistently done every 72 hours as prescribed, and medication administration records did not align. Staff failed to wake R2 to administer routine medications at prescribed times. The call light response allegation was found unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87465(a)(4) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by failure to comply for two residents (R1 and R2), posing an immediate health and safety risk. | Type A |
Report Facts
Facility census: 75
Facility capacity: 125
Call lights average per day: 62
Call lights response time: 95
Call lights delayed response: 3
Medication administration dates for R1 fentanyl patch: 9
Medication administration dates for R1 fentanyl patch: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sanjuana Enriquez | Administrator | Facility administrator met during the investigation and involved in findings |
| Martha Reynolds | Clinical Resource | Met during initial visit and involved in medication audit |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 125
Deficiencies: 0
Feb 6, 2023
Visit Reason
The visit was conducted as a complaint investigation following an allegation that staff failed to provide supervision, resulting in Resident #1 sexually assaulting Resident #2.
Findings
The investigation found that Resident #1 and Resident #2 maintained a mutual consensual relationship, and there was insufficient evidence to support the allegation of neglect or lack of supervision leading to sexual assault. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged neglect/lack of supervision resulting in Resident #1 sexually assaulting Resident #2. The investigation included interviews with staff, residents, witnesses, and review of medical and facility documents. The allegation was found unsubstantiated based on evidence and interviews.
Report Facts
Capacity: 125
Census: 79
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Eric Terrill | Executive Director | Interviewed during the investigation |
| Ashley Villarreal | Community Liaison Director | Met with during the investigation and exit interview |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Christine Ferris | Investigator | Assigned to the complaint investigation |
Inspection Report
Annual Inspection
Census: 78
Capacity: 125
Deficiencies: 0
Oct 19, 2022
Visit Reason
An unannounced on-site annual infection control visit was conducted to assess the facility's compliance with infection control requirements.
Findings
The facility had appropriate infection control signage, hand hygiene supplies, and fire extinguishers in place. Staff were wearing masks and screening was conducted upon entry. No deficiencies were cited during the inspection.
Report Facts
Fire extinguisher inspection dates: Fire extinguishers inspected on 4/12/22 and kitchen extinguisher on 4/29/22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Terrill | Executive Director/Administrator | Met with Licensing Program Analyst during inspection and discussed infection control practices |
| Darlene Chavez | Licensing Program Analyst | Conducted the inspection and infection control mitigation module |
| Kelly Burley | Licensing Program Manager | Named in report header |
Inspection Report
Census: 73
Capacity: 125
Deficiencies: 1
Aug 31, 2022
Visit Reason
The visit was a Case Management - Deficiencies inspection conducted to evaluate compliance with medication administration requirements.
Findings
The licensee failed to administer prescribed medication (Escitalopram 5 mg) to resident R1 on three consecutive days due to lack of medication supply, posing an immediate health risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assist residents with self-administered medications as required, resulting in R1 not receiving Escitalopram 5 mg on 2/17/22, 2/18/22, and 2/19/22. | Type A |
Report Facts
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Villarreal | Community Liaison Director | Met with Licensing Program Analyst during the visit and authorized to review and sign reports |
| Joann Rosales | Licensing Program Analyst | Conducted the Case Management - Deficiencies visit and authored the report |
| Kristin Heffernan | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 125
Deficiencies: 3
Aug 31, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to complaints received on 02/22/2022 regarding resident care issues at Lexington Assisted Living Facility.
Findings
The investigation substantiated that resident #1 was left soiled for a long period, did not have access to personal possessions (hearing aids), and staff did not provide meals to the resident on 2/19/22. Allegations that the resident's call button was inoperable and that medication was not provided timely were unsubstantiated.
Complaint Details
Complaint investigation was substantiated for allegations that resident #1 was left soiled for a long period, did not have access to personal possessions, and was not provided meals on 2/19/22. Allegations regarding inoperable call button and untimely medication were unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide at least three meals per day as breakfast and lunch were not made available to resident #1 on 2/19/22. | Type B |
| Failure to ensure incontinent residents are kept clean and dry; resident #1 was left soiled for an extended period. | Type A |
| Failure to ensure resident has access to personal possessions; resident #1 did not have access to hearing aids on 2/19/22. | Type B |
Report Facts
Capacity: 125
Census: 73
Deficiency count: 3
Plan of Correction Due Date: Sep 1, 2022
Plan of Correction Due Date: Sep 12, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joann Rosales | Licensing Program Analyst | Conducted complaint investigation and delivered final findings |
| Ashley Villarreal | Community Liaison Director | Met with Licensing Program Analyst and authorized to review and sign reports |
| Sanjuana Enriquez | Administrator | Facility administrator named in the report |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 73
Capacity: 125
Deficiencies: 1
Aug 23, 2022
Visit Reason
The visit was a Case Management - Deficiencies inspection conducted to evaluate compliance with regulations and identify any deficiencies at the Lexington Assisted Living Facility.
Findings
A deficiency was cited for storing disinfectants and toxic substances accessible to residents with dementia, posing an immediate health risk. A civil penalty of $250 was issued.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Disinfectants and toxic items were observed accessible to residents with dementia, violating storage requirements. | Type A |
Report Facts
Civil penalty amount: 250
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Terrill | Administrator | Met with Licensing Program Analyst during the inspection |
| Joann Rosales | Licensing Program Analyst | Conducted the Case Management - Deficiencies visit |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 125
Deficiencies: 1
Aug 23, 2022
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2021-09-10 regarding allegations that facility staff handled residents roughly and spoke inappropriately to residents.
Findings
The investigation substantiated that facility staff handled residents roughly while assisting with toileting and transferring, causing extreme pain but no injuries. The allegation that staff spoke inappropriately to residents was unsubstantiated.
Complaint Details
The complaint was substantiated regarding rough handling of residents causing extreme pain during toileting and transferring, but unsubstantiated regarding inappropriate speech by staff to residents.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to comply with HSC 1569.269(a)(10) regarding residents' rights to be free from neglect, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse, evidenced by residents being handled roughly by staff posing an immediate health, safety, and personal rights risk. | Type A |
Report Facts
Capacity: 125
Census: 73
Deficiency Type: 1
Plan of Correction Due Date: Aug 24, 2022
Staff inservice documentation due date: Sep 2, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joann Rosales | Licensing Program Analyst | Conducted the complaint investigation and delivered final findings |
| Eric Terrill | Facility representative met during investigation | |
| Sanjuana Enriquez | Administrator | Facility administrator named in report |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 125
Deficiencies: 1
Aug 8, 2022
Visit Reason
An unannounced Case Management visit was conducted to discuss an alleged incident reported to Community Care Licensing on 08/05/2022 regarding resident #1 and resident #2.
Findings
During the visit, toxic items such as paint, painter's acrylic latex caulk, fragrance mist, and body lotion were observed accessible to residents, which poses an immediate health risk. A deficiency was cited under Title 22 Division 6 Chapter 8 of the CA Code of Regulations, and a civil penalty of $250 was issued.
Complaint Details
The visit was complaint-related, investigating an alleged incident involving residents #1 and #2 reported on 08/05/2022. The deficiency cited was substantiated by observations during the visit.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Toxic items were observed accessible to residents, violating the requirement that such items be stored inaccessible to residents with dementia. | Type A |
Report Facts
Civil penalty amount: 250
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sanjuana Enriquez | Administrator | Met with Licensing Program Analyst during the visit |
| Eric Terrill | Executive Director | Met with Licensing Program Analyst and accompanied facility tour |
| Joann Rosales | Licensing Program Analyst | Conducted the unannounced Case Management visit and investigation |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the licensing program and cited deficiency |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 125
Deficiencies: 1
Aug 8, 2022
Visit Reason
An unannounced complaint investigation visit was conducted due to allegations that residents' personal rights were being violated because of lack of supervision, specifically concerning inappropriate touching and verbal behavior by resident #1.
Findings
The investigation substantiated the allegation that resident #1 was inappropriately touching female residents and speaking inappropriately to them, posing an immediate safety and personal rights risk. Staff interviews and record reviews confirmed these behaviors, and the facility was cited for failing to protect residents' rights.
Complaint Details
The complaint was substantiated. Allegations involved resident #1 inappropriately touching female residents and making verbal advances. Interviews and record reviews supported these findings. Resident #1 denied the behaviors, and resident #2 could not be interviewed due to diagnosis.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents' personal rights are not violated, specifically allowing resident #1 to engage in inappropriate touching and verbal abuse. | Type A |
Report Facts
Capacity: 125
Census: 70
Deficiency Type: 1
Plan of Correction Due Date: Aug 9, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joann Rosales | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sanjuana Enriquez | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
| Eric Terrill | Executive Director | Facility executive director toured facility with Licensing Program Analyst |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 125
Deficiencies: 1
Jul 27, 2022
Visit Reason
The inspection visit was conducted due to deficiencies observed during the investigation of complaint control #29-AS-20220726081704.
Findings
The inspection found that the door to the facility's in-ground pool was unlocked, posing an immediate health and safety risk to persons in care. Civil penalties of $500 were issued for this zero-tolerance violation.
Complaint Details
The visit was triggered by complaint control #29-AS-20220726081704. The deficiency was substantiated as the unlocked pool gate was observed during the investigation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The gate leading to the swimming pool was not locked, which poses an immediate health and safety risk to persons in care. | Type A |
Report Facts
Civil penalty amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and cited the deficiency. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the inspection. |
| Martha Reynolds | Clinical Resource | Met with the Licensing Program Analyst during the inspection. |
Inspection Report
Census: 68
Capacity: 125
Deficiencies: 2
Apr 12, 2022
Visit Reason
The visit was a Case Management - Deficiencies inspection conducted to evaluate compliance with licensing regulations and identify any deficiencies at the Lexington Assisted Living Facility.
Findings
Two Type A deficiencies were cited: one for storing dishwashing liquid accessible to residents with dementia, posing an immediate health risk, and another for allowing a staff member to work without proper criminal record clearance, posing an immediate safety risk. Civil penalties totaling $3,250 were issued.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Dishwashing liquid was observed accessible to residents with dementia, violating storage requirements for toxic substances. | Type A |
| Staff member (S1) was allowed to work without proper criminal record clearance prior to employment. | Type A |
Report Facts
Civil penalties: 3250
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sanjuana Enriquez | Administrator | Met with Licensing Program Analyst during inspection and referenced regarding staff employment |
| Joann Rosales | Licensing Program Analyst | Conducted the Case Management - Deficiencies visit |
| Kristin Heffernan | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 125
Deficiencies: 1
Apr 12, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that residents were not getting changed timely.
Findings
The investigation substantiated the allegation that residents were not being changed timely, posing a potential health and personal rights risk. Interviews and record reviews confirmed delays in care and multiple calls for help by residents.
Complaint Details
The complaint was substantiated based on interviews and record reviews showing residents were not changed timely, with documented calls for help and caregiver notes indicating neglect in care.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide basic services including timely care and supervision as required by CCR 87464(f)(1), resulting in residents not being changed timely. | Type B |
Report Facts
Capacity: 125
Census: 68
Deficiency count: 1
Plan of Correction Due Date: Apr 22, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joann Rosales | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sanjuana Enriquez | Administrator | Facility administrator met during investigation and named in findings |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 125
Deficiencies: 1
Apr 12, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that residents were not administered medication as prescribed.
Findings
The investigation found that residents were indeed not administered their medications as prescribed, with staff admitting to being distracted and forgetting to give medications. The allegation was substantiated.
Complaint Details
The complaint was substantiated based on interviews and observations that residents were missing medications when staff administered them, and staff admitted to distraction and omission.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Residents were not administered their medications as prescribed, violating HSC 1569.269(a)(6) regarding residents' rights to care and supervision that meet their individual needs. | Type B |
Report Facts
Capacity: 125
Census: 68
Deficiency Type: 1
Plan of Correction Due Date: Apr 22, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joann Rosales | Licensing Program Analyst | Conducted the complaint investigation and delivered final findings |
| Sanjuana Enriquez | Administrator | Facility administrator met during investigation and named in findings |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 72
Capacity: 125
Deficiencies: 0
Mar 8, 2022
Visit Reason
The visit was an informal conference conducted to discuss the facility's failure to report a COVID-19 outbreak in February 2022.
Findings
The Licensing Program Manager discussed substantiated complaints and citations from the past three years and reviewed the Administrator's plans to maintain compliance. The Operations Manager described staffing improvements and safety measures implemented, including delegation of reporting duties and securing medications and hazardous items.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SanJuana Enriquez | Administrator | Named as the facility Administrator involved in the informal conference and compliance discussion. |
| Kristin Heffernan | Licensing Program Manager | Conducted the informal conference and discussed substantiated complaints and citations. |
| JoAnn Rosales | Licensing Program Analyst | Attended the informal conference. |
| Matteo DiGrigoli | Operations Manager | Discussed staffing and safety measures during the informal conference. |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 125
Deficiencies: 1
Feb 24, 2022
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility did not report an outbreak of COVID-19.
Findings
The investigation found that the facility failed to report COVID-19 positive residents to Community Care Licensing and Ventura County Public Health between 2/4/22 and 2/16/22, substantiating the complaint. Documentation showed 19 residents were COVID positive during that period, but no notification was made as required.
Complaint Details
The complaint was substantiated. The licensee did not report COVID positive residents to Community Care Licensing and Ventura County Public Health from 2/4/22 to 2/16/22, posing a potential health and personal rights risk to persons in care.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report epidemic outbreaks as required by CCR 87211(a)(2), specifically not reporting COVID positive residents to licensing agency and local health officer within 24 hours. | Type B |
Report Facts
COVID positive residents: 19
Census: 75
Total Capacity: 125
Plan of Correction Due Date: 03/07/2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joann Rosales | Licensing Program Analyst | Conducted the complaint investigation |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Matteo Digrigoli | Operations Manager | Facility representative who met with Licensing Program Analyst and provided information during investigation |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 125
Deficiencies: 1
Feb 24, 2022
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that Resident #1 sustained multiple fractures while in care at the facility.
Findings
The allegation of neglect/lack of supervision resulting in multiple injuries to Resident #1 was substantiated. The facility failed to provide adequate care and supervision, which contributed to the resident sustaining multiple injuries including fractures and falls. A $500 immediate civil penalty was assessed.
Complaint Details
The complaint was substantiated. Resident #1 sustained multiple fractures including a broken nose, compression fractures of L1 and L3, and 5 broken ribs. Multiple falls were documented, some unwitnessed, and the facility failed to provide adequate supervision and care. A $500 immediate civil penalty was issued.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate care and supervision to Resident #1, resulting in multiple injuries due to falls, posing an immediate health and safety risk. | Type A |
Report Facts
Civil penalty amount: 500
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joann Rosales | Licensing Program Analyst | Conducted the complaint investigation and subsequent visit |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
| Matteo DiGrigoli | Operations Manager | Met with during the visit and informed of findings and penalties |
| Dennis Douglas | Investigator | Conducted interviews and records review related to the complaint investigation |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 125
Deficiencies: 5
Feb 24, 2022
Visit Reason
The visit was a Case Management - Deficiencies inspection conducted due to a complaint investigation regarding resident care and facility safety.
Findings
The inspection found multiple deficiencies including unsafe storage of hazardous items accessible to residents, unassociated staff working at the facility, and failure to update a resident's Needs and Services Plan to reflect changes in condition. Civil penalties were issued totaling $1,800.
Complaint Details
The complaint investigation (#29-AS-20210226132843) revealed that Resident #1's Needs and Services Plan had not been updated to reflect changes in condition after multiple falls and cognitive decline, and that an unassociated staff member worked at the facility.
Severity Breakdown
Type A: 4
Type B: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Disinfectants, cleaning solutions, poisons, firearms and other dangerous items were accessible to residents, posing an immediate health and safety risk. | Type A |
| Staff member S1 worked at the facility without being properly associated or cleared, posing an immediate safety risk. | Type A |
| Scissors were accessible to residents with dementia, posing an immediate health, safety or personal rights risk. | Type A |
| Resident #2's medications were accessible to residents, posing an immediate health and safety risk. | Type A |
| Resident #1's Needs and Services Plan was not updated to reflect a change of condition, posing a potential health and safety risk. | Type B |
Report Facts
Civil penalties issued: 250
Civil penalties issued: 250
Civil penalties issued: 1300
Total civil penalties: 1800
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matteo DiGrigoli | Operations Manager | Met with Licensing Program Analyst during inspection and authorized to review and sign reports. |
| Lidia Padilla | Facility Wellness Director | Acknowledged that Resident #1’s Needs and Services Plan had not been updated. |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 125
Deficiencies: 1
Jan 4, 2022
Visit Reason
An unannounced complaint investigation was conducted due to allegations that unqualified staff were administering medication at Lexington Assisted Living Facility.
Findings
The investigation substantiated that staff member S1 had not completed the required annual medication training, having last received training six years prior, which poses a potential health risk to residents.
Complaint Details
The complaint was substantiated based on interviews and record reviews indicating that unqualified staff administered medication without current annual training.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to complete annual medication training as required by HSC 1569.69(b), posing a potential health risk to persons in care. | Type B |
Report Facts
Capacity: 125
Census: 75
Deficiency count: 1
Medication training hours: 16
Plan of Correction due date: Jan 14, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joann Rosales | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Matteo Digrigoli | Operations Manager | Met with Licensing Program Analyst during the investigation and authorized report review and signing |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 125
Deficiencies: 1
Jan 4, 2022
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility transportation vehicle was in disrepair, specifically needing new windshield wipers.
Findings
The investigation found that the facility vehicle's windshield wipers were cracked and had not been replaced in at least two years, the right front tire was balding, and the vehicle registration tags were expired. These conditions posed a potential safety and personal rights risk to residents.
Complaint Details
The complaint was substantiated based on observations and interviews during the unannounced visit. The Operations Manager was unaware of the vehicle's maintenance issues. The allegation was deemed substantiated at the time of the investigation.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility van is not maintained in a safe operating condition, including cracked windshield wipers, balding front passenger tire, and expired vehicle registration tags. | Type B |
Report Facts
Capacity: 125
Census: 75
Plan of Correction Due Date: Jan 14, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joann Rosales | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Matteo Digrigoli | Operations Manager | Facility representative met during investigation and authorized to review and sign reports |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 125
Deficiencies: 0
Jan 4, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff were retaliating against a resident for filing a complaint.
Findings
The Licensing Program Analyst toured the facility, interviewed random residents and staff, and found no evidence of retaliation by staff against any resident for filing a complaint. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that facility staff were retaliating against a resident for filing a complaint. After investigation, including interviews on multiple dates, the allegation was found to be unsubstantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joann Rosales | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Matteo Digrigoli | Operations Manager | Met with the Licensing Program Analyst and authorized to review and sign reports. |
| Kristin Heffernan | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 125
Deficiencies: 0
Dec 1, 2021
Visit Reason
The visit was an unannounced complaint investigation initiated due to allegations received on 10/25/2021 regarding inappropriate touching of a resident by another resident and staff not preventing verbal altercations among residents.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Resident and staff interviews revealed no inappropriate touching occurred, and verbal altercations between residents were managed by staff. Both allegations were determined to be unsubstantiated.
Complaint Details
The complaint alleged that a resident was inappropriately touched by another resident and that staff failed to prevent verbal altercations between residents. After interviews and investigation, both allegations were found unsubstantiated due to lack of evidence.
Report Facts
Complaint Control Number: 29-AS-20211025144923
Facility Capacity: 125
Census: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Matteo DiGrigoli | Operations Manager | Met with during inspection and interviewed regarding allegations |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 125
Deficiencies: 3
Nov 18, 2021
Visit Reason
An unannounced complaint investigation was conducted following allegations including untrained staff handing out medications, lack of an Activities Director, and internet disrepair at the facility.
Findings
The investigation substantiated that staff assisted residents with medications without proper training, the facility lacked an Activities Director for approximately a month, and the facility's internet was intermittently non-functional, posing potential risks to residents.
Complaint Details
The complaint investigation was substantiated based on findings that staff without medication training assisted residents, the facility lacked an Activities Director for over a month, and the internet was in disrepair causing intermittent outages.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Employees assisting residents with self-administration of medication without completing required medication training. | Type B |
| Facility did not have an Activities Director as required for facilities licensed for fifty or more persons. | Type B |
| Facility internet was not working properly, causing potential personal rights risk to persons in care. | Type B |
Report Facts
Capacity: 125
Census: 70
Plan of Correction Due Date: Nov 23, 2021
Medication training hours required: 24
Internet outage date: Sep 15, 2021
Internet part delivery time: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joann Rosales | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Matteo Digrigoli | Operations Manager | Met with Licensing Program Analyst during investigation and provided statements regarding deficiencies |
| Sanjuana Enriquez | Administrator | Facility Administrator named in the report |
Inspection Report
Annual Inspection
Census: 70
Capacity: 125
Deficiencies: 3
Nov 18, 2021
Visit Reason
The inspection was a required unannounced annual visit with a specific emphasis on infection control practices and procedures.
Findings
The facility was generally in compliance with health and safety regulations, but several deficiencies were found related to unsecured hazardous items accessible to residents with dementia and outdated physician reports for some residents. Three citations were issued along with a civil penalty for repeat violations.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Pliers, screwdrivers, and scissors were accessible to residents with dementia, posing an immediate health, safety, or personal rights risk. | Type A |
| Over-the-counter and prescription medication bottles, laundry soap, and dish soap were found in an unlocked room accessible to residents, posing an immediate health, safety, or personal rights risk. | Type A |
| Six residents did not have a current Physician's Report, posing a potential health, safety, or personal rights risk. | Type B |
Report Facts
Citations issued: 3
Civil penalty amount: 250
Residents without current Physician's Report: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matteo DiGrigoli | Operations Manager | Discussed reason for visit and involved in securing hazardous items. |
| Angel Ascencio | Licensing Program Analyst | Conducted inspection and authored report. |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Census: 71
Capacity: 125
Deficiencies: 3
Oct 14, 2021
Visit Reason
The visit was a Case Management - Deficiencies inspection conducted to evaluate compliance with licensing requirements and to address observed deficiencies.
Findings
The inspection found multiple deficiencies including unsecured medications and toxic substances accessible to residents with dementia, centrally stored medicines not kept locked, and an unauthorized staff member working without proper association documentation. Civil penalties of $750 were issued.
Severity Breakdown
Type A: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Over-the-counter medication, vitamins, and toxic substances were observed accessible to residents with dementia, posing an immediate health and safety risk. | Type A |
| Resident medications were observed accessible to residents and not kept in a safe and locked place accessible only to authorized employees. | Type A |
| Licensee did not ensure that staff member S1 was associated prior to allowing them to work, posing an immediate safety risk to residents. | Type A |
Report Facts
Civil penalty amount: 750
Deficiency count: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matteo DiGrigoli | Operations Manager | Met with Licensing Program Analyst during inspection and authorized to review and sign reports. |
| Joann Rosales | Licensing Program Analyst | Conducted the Case Management - Deficiencies visit and signed the report. |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Follow-Up
Census: 70
Capacity: 125
Deficiencies: 2
Sep 13, 2021
Visit Reason
This Case management visit was conducted to address the deficiencies noted during complaint control #29-AS-20210910084322 investigation visit conducted on 9/13/21.
Findings
The licensee did not comply with regulations requiring that medications, alcohol, cleaning supplies, and disinfectants be stored inaccessible to residents, posing an immediate safety risk to persons in care.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Medication, alcohol, cleaning supplies and disinfectants were observed accessible to residents with dementia, violating storage requirements. | Type A |
| Centrally stored medicines were not kept in a safe and locked place, as resident #1's medications were accessible to other residents. | Type A |
Report Facts
Capacity: 125
Census: 70
Plan of Correction Due Date: Sep 14, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matteo Digrigoli | Operations Manager | Met during inspection and involved in findings |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the inspection |
| Joann Rosales | Licensing Program Analyst | Licensing evaluator conducting the inspection |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 125
Deficiencies: 2
May 28, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that facility staff shut off the water supply for a prolonged period and did not provide advance notice of the water shut-off to residents.
Findings
The investigation substantiated both allegations: the water supply was shut off on May 20th from 10pm to 4am due to repairs, and the facility failed to provide advance notice to residents about the water shut-off. These failures posed potential health and safety risks to residents.
Complaint Details
The complaint investigation was substantiated. The facility staff shut off the water supply for a prolonged period on May 20th from 10pm to 4am and did not provide advance notice to residents, posing potential health and safety risks.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to provide a safe and healthful environment as water was not available from 10pm to 4am on May 20th. | Type B |
| Facility failed to provide advanced notice to residents of the water shut-off on May 20th between 10pm and 4am. | Type B |
Report Facts
Capacity: 125
Census: 75
Plan of Correction Due Date: Jun 4, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Balisi | Licensing Program Analyst | Conducted the complaint investigation and cited deficiencies |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation and deficiency citations |
| Lidia Padilla | Wellness Director | Met with investigators during the complaint investigation |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 125
Deficiencies: 0
May 24, 2021
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations that the food provided at the facility was not nutritionally adequate.
Findings
The investigation found insufficient evidence to support the claim that the food was nutritionally inadequate. Observations and resident interviews indicated sufficient food from all food groups, with food labels up to date and residents satisfied with the quality and quantity of food.
Complaint Details
The complaint alleging that the food was not nutritionally adequate was investigated and deemed unsubstantiated based on observations and resident interviews.
Report Facts
Capacity: 125
Census: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Martha Guzman-Chavez | Licensing Program Analyst | Conducted the complaint investigation |
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Matteo Digrigoli | Operations and Marketing Director | Interviewed during the investigation |
| Lidia Padilla | Wellness Director | Interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 125
Deficiencies: 1
May 24, 2021
Visit Reason
This case management visit was conducted to address the deficiencies noted during complaint control #29-AS-20210521142052 investigation visit conducted on 5/24/2021.
Findings
During the facility tour, storage closets containing gallons of paint were found open and accessible to residents, posing a potential health and safety risk. Deficiencies were cited pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations.
Complaint Details
Visit was complaint-related, addressing deficiencies noted during complaint control #29-AS-20210521142052. Substantiation status is not explicitly stated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Storage closet containing gallons of paint was left open and accessible to residents, posing a potential health and safety risk. | Type B |
Report Facts
Deficiency POC due date: May 31, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt DiGrigoli | Operations and Marketing Director | Met during facility tour and exit interview |
| Lidia Padilla | Wellness Director | Met during facility tour and exit interview |
| Kelly Dulek | Licensing Program Analyst | Conducted inspection, cited deficiencies, signed report |
| Kristin Heffernan | Licensing Program Manager | Supervisor and Licensing Program Manager named in report |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 125
Deficiencies: 1
Feb 23, 2021
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following an allegation that the facility failed to report a scabies outbreak.
Findings
The allegation was substantiated. The investigation found that the facility did not complete and submit incident reports or notify the Department of Public Health regarding the scabies outbreak affecting residents and staff.
Complaint Details
The complaint was substantiated based on interviews and investigation findings that the facility failed to report a scabies outbreak affecting 5 residents and 8 staff, and did not notify the Department of Public Health as required.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to complete and submit incident reports and notify Department of Public Health regarding scabies outbreak. | Type B |
Report Facts
Residents diagnosed with scabies: 5
Staff diagnosed with scabies: 8
Deficiencies cited: 1
Plan of Correction due date: Mar 1, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joann Rosales | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
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