Lexington House

Allegation investigated: Staff did not provide adequate supervision resulting in resident eloping.

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced visit to conduct a complaint investigation and delivered findings regarding the above mentioned allegation. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit to caregivers Ann Cunanan and Jennifer Cinco. Administrator Arceli Songco arrived later during the visit. Note, LPA did step out for lunch from 12:00-1:00pm. On 05/19/2026, the Department received a complaint where it was alleged that a resident (identified as R1) had eloped from the facility due to lack of staff supervision. The Department’s investigation consisted of an unannounced facility visit, records review, and interviews with staff, residents, and outside sources. [Continued on LIC 9099-C] Unsubstantiated [Continued from LIC 9099] R1 is a resident at the facility with a diagnosis of Dementia, along with multiple other diagnoses of conditions that affect R1's mental health and cognitive functioning. Per R1's medical assessment, conducted October 2025, R1 is unable to leave the facility unassisted. R1 had been residing at the facility for over four (4) years under the current ownership that acquired the facility back in 2022. Community Care Licensing (CCL) had received an incident report from the facility on 5/19/26 of the incident where R1 had eloped from the facility a few days prior on 5/15/26. Per the report, it is noted that one caregiver was assisting another resident and another caregiver was completing medication documentation at the medication desk and neither heard the door alarm activate when R1 exited the facility. It is noted that R1 was last seen watching tv in the living room area. Per the report, Staff searched the facility and surrounding neighborhood, then subsequently contacted law enforcement for assistance. Just over an hour later, the facility received a call from an individual who found R1 about 0.8 miles away from the facility and noted scratches and abrasions to the face and both knees. R1 was taken to the hospital for evaluation and returned to the facility same day with no serious injuries. Staff interviews corroborated the events detailed in the report received by CCL, with multiple staff revealing that R1 had wandering behaviors within the home and yard, but had never been exit seeking from the property until this recent incident. It was corroborated by all staff that R1 enjoyed walking. Two (2) staff interviewed indicated that R1 had only ever left the facility before with direct staff supervision, and another indicated that R1 would communicate with staff when they were wanting to go on a walk. Interviews with staff present during the elopement incident revealed that they had last heard R1 laughing while watching tv in the living room just minutes before realizing R1 was no longer there. Interviews with outside sources responsible for R1's care corroborated that this was the first incident they were aware of for R1 displaying eloping/exit seeking behaviors at the home. These interviews also revealed no concern with the facility's ability to supervise and care for R1 thus far, and indicated they felt the facility responded to the incident appropriately. Interviews with residents revealed no concerns about their care, staffing numbers, or staff response times. [Continued on LIC 9099-C] [Continued from LIC 9099] File review of R1's physician's assessment noted that R1 had wandering behaviors but no elopement behaviors. Per review of R1's annual appraisal, conducted January 2026, R1 was not noted to require specialized supervision and/or night supervision. Per review of R1's care plan, dated March 2026, it's noted that staff will continue to monitor R1 for wandering or unsafe behaviors, not specifying any specialized supervision needs. Since the incident, the facility has responded by increasing monitoring of R1 and implemented additional training on elopement, as corroborated by staff interviews. Based on interviews and records review, while the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred – therefore the allegation has been determined to be UNSUBSTANTIATED. An exit interview was conducted with Administrator Songco to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 29, 2026 · control 08-AS-20260519142545

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Renita Hall conducted an unannounced annual required visit to the above-mentioned facility. Upon arrival, LPA met with the Administrator. The facility operates as a Residential Care for the Elderly (RCFE) facility for individuals aged 60 and over and accepts Dementia residents. A facility tour was conducted, which included indoor activity areas, restrooms, kitchens, and outdoor space. All areas were clean, safe, and in good repair. Furniture and equipment were in good condition and appropriate for the clients in care. The facility has sufficient space and seating for all clients, with no exit obstructions. Restrooms were equipped with grab bars and adequate supplies. Hot water temperature measured within the required range of 105°F to 120°F, with signs posted for caution: hot water. Meals are prepared by staff, and menus were available at the time of visit. A random sample of client files was reviewed. Files contained current physicians’ reports, admission agreements, emergency information, needs and services plans, and other required documentation. Staff records reviewed contained criminal record clearance, health screening, current first aid/CPR certification, and required training. Continued on 809C Supervision was observed to be appropriate, and staff were seen interacting with clients in a respectful and supportive manner. LPA interviewed 3 staff and 2 clients. No concerns were noted. The facility’s emergency disaster plan was observed to be current and posted. Fire drills are conducted as required, and documentation is available for review. Fire extinguishers were serviced within the past year, and smoke/carbon monoxide detectors were operable. No deficiencies were cited during today’s visit. An exit interview was conducted with the Administrator, and a copy of this report, along with the Licensee Rights (LIC 9058), was provided to the Administrator. Her signature on this form confirms receipt of the documents.the state’s words, verbatim · CDSS document, Jan 21, 2026

Allegation investigated: Facility staff allowed resident to remain in soiled diaper overnight

Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to deliver findings regarding the allegation mentioned above. LPA was allowed entry the caregiver. LPA identified herself and disclosed the purpose of the visit and elements of the complaint to the caregiver. LPA conducted a facility tour and observed no concerns related to resident hygiene or incontinence care practices. LPA conducted interviews with facility staff, residents, and attempted interviews with outside sources and Resident 1 (R1). LPA spoke with the Administrator, who confirmed that R1 is no longer at the facility and has been relocated to a Skilled Nursing Facility (SNF) after being discharged from the hospital. R1 was able to communicate their needs and did not have a cognitive impairment, although occasional forgetfulness was noted. Interviewed with R1’s primary caregiver Staff 2 (S2) revealed that R1 had access to a call bell, and staff responded to calls. Unsubstantiated S2 also confirmed that routine incontinence checks were performed per facility protocol. Per the LIC 602 dated March 7, 2025, R1 is medically stable at their baseline and requires minimal assistance with transfers. R1 experiences frequent episodes of incontinence; however, there is no documentation of current skin breakdown. R1 has episodes of forgetfulness, but no formal cognitive impairment is documented. She required set-up assistance with grooming and feeding, minimal assistance with bathing, and maximum assistance with toileting needs. Additional interviews were conducted with residents who all stated they did not have any incontinence issues and were able to handle their own toileting needs. LPA attempted to interview an outside source with no success due to the hostile interaction. Based on the information gathered through interviews, observations, and record reviews, the allegation is unsubstantiated. There was insufficient evidence to support the allegation that R1 was left in a soiled diaper overnight. A finding that is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted with the Caregiver. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Caregiver, and her signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Jun 27, 2025 · control 08-AS-20250404130608

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced Required 1 year Annual Visit. LPA was allowed entry by Lolita Perez, Caregiver. LPA identified herself and disclosed the purpose of the visit with the caregiver. Arceli Songco, Administrator, joined this visit later. Physical Environment: The facility was clean, well-maintained, and free from any safety hazards. Adequate lighting and ventilation were observed in all areas of the facility. All necessary safety equipment, such as fire extinguishers and emergency exits, were present and in good working condition. The facility's outdoor spaces were properly maintained and accessible to residents. Staffing and Training: The facility had a sufficient number of qualified staff members to meet the residents' needs. The staff members were observed to be professional, courteous, and knowledgeable in their respective roles. All staff members had completed the required training and certifications per the licensing regulations. Staffing schedules were posted and adhered to, ensuring adequate coverage. Resident Care and Services: Residents' care plans were reviewed and found to be comprehensive and up-to-date. Medication administration was observed to be following the facility's policies and procedures. Residents' nutritional needs were met, and the meals provided were nutritious and well-balanced. Recreational activities and social engagement opportunities were available to residents regularly. Health and Safety: Regular health assessments and monitoring of residents' well-being were conducted by qualified healthcare professionals. Infection control measures were in place and followed by staff members. The facility had established protocols for emergencies and evacuation plans were readily available. Overall, the facility was found to comply with the licensing regulations. An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058) was provided to Arceli Songco, Administrator. Her signature on this form confirms receipt of the documents.the state’s words, verbatim · CDSS document, Jan 22, 2025

Allegation investigated: Staff did not meet resident’s dietary needs Staff did not maintain resident's hygeine Staff did not provide resident with basic services resulting in dehydration

Licensing Program Analyst (LPA) Ramon Serrano, conducted an unannounced visit to deliver complaint findings. LPA introduced himself and discussed the purpose of the visit with Administrator Arceli Songco. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review and interviews with facility staff and outside sources. It was reported to CCL that facility staff were not meeting Resident 1's (R1)(an LIC 811 Confidential Names List was provided to the facility representative to identify the resident) dietary needs. Staff members and Administrator were interviewed, and it was determined that they followed the established dietary guidelines for R1 indicated in R1's medical records. Menus were appropriately adjusted based on individual needs. No evidence was found to substantiate the allegation of staff not meeting R1's dietary needs. Unsubstantiated Staff practices related to hygiene were reviewed. It was observed that regular hygiene routines were followed, including bathing, grooming, and changing of clothes. R1 was provided with necessary supplies (e.g., toiletries, clean linens). No evidence was found to support the claim of inadequate hygiene maintenance. LPA direct observation revealed R1 had a water bottle at R1's bedside as well as access to food and fluids. Interviews with facility staff revealed; staff members consistently provided basic services such as hydration, toileting, and assistance with daily activities to R1. The allegation of staff negligence resulting in dehydration was not substantiated. R1 was regularly offered fluids, and no patterns of neglect were identified. LPA interviewed R1's responsible party (RP). RP expressed confidence in the facility and the facility staff. According to RP, they have had no previous issues or concerns related to the quality of care that R1 has received while at the facility. RP stated that facility staff cannot force R1 to drink fluids and when R1 is thirsty R1 will ask staff for water. RP stated that they are having some internal family issues where a certain family member wants R1 transferred to a medical facility and also wants to become R1's responsible party or power of attorney. Records review revealed Administrator had been in regular contact with both R1's responsible party as well as outside parties that were not privy to R1's confidential medical records or information. LPA interviewed Administrator who stated that she has been in regular contact with R1's responsible party since R1 was recently admitted to the facility. Administrator stated that R1's responsible party is happy with care that R1 has been receiving while at the facility and stated that they plan on transferring R1 back to the facility once R1 is discharged from the skilled nursing facility that R1 is currently at. Administrator stated that R1's dietary needs were met daily according to R1's physician's report. Administrator stated that although R1 was not ambulatory all of R1's hygiene needs were met, including; bathing, sponge baths, grooming, etc. Administrator stated that R1 was regularly given fluids by facility staff and dehydration was never noted on any of R1's hospital discharge documents. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. An exit interview was conducted with Arceli Songco. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Arceli Songco whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, May 29, 2024 · control 08-AS-20240429125831

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced Required 1 year Annual Visit. LPA was allowed entry by Khyzzer Coranez, Caregiver. LPA identified herself and disclosed the purpose of the visit with the Caregiver and was later joined by Arceli Songco, Administrator. Physical Environment: The facility was clean, maintained, and free from any safety hazards. Adequate lighting and ventilation were observed in all areas of the facility. All necessary safety equipment, such as fire extinguishers and emergency exits, were present and in good working condition. The facility's outdoor spaces were properly maintained and accessible to residents. Staffing and Training: The facility had a sufficient number of qualified staff members to meet the needs of the residents. The staff members were observed to be professional, courteous, and knowledgeable in their respective roles. All staff members had completed the required training and certifications per the licensing regulations. Staffing schedules were posted and adhered to, ensuring adequate coverage at all times. Continue on 809C Resident Care and Services: Residents' care plans were reviewed and found to be comprehensive and up-to-date. Medication administration was observed to be in accordance with the facility's policies and procedures. Residents' nutritional needs were met. Recreational activities and social engagement opportunities were available to residents regularly. Health and Safety: Regular health assessments and monitoring of residents' well-being were conducted by qualified healthcare professionals. Infection control measures were in place and followed by staff members. The facility had established protocols for emergencies and evacuation plans were readily available. Overall, the facility was found to comply with the licensing regulations. An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058) was provided to the Administrator. Her signature on this form confirms receipt of the documents.the state’s words, verbatim · CDSS document, Jan 23, 2024