Lexington Assisted Living

Licensing Program Analyst (LPA) Teresa Camara conducted a complaint investigation visit regarding the above noted allegations. LPA met with administrator Jill Morris Chapman and explained the reason for the visit. At 1:05 p.m. LPA interviewed administrator. At 1:25 p.m. and 1:40 p.m. LPA interviewed staff. At 1:50 p.m. LPA conducted a room inspection in the former room of resident 1 (R1). Regarding the allegation facility staff locked resident in bedroom: The door was locked so that other residents could not wander into R1's room. This was for R1's safety and preference as R1 did not like other residents in their room. R1's door could be opened from the inside by just turning the door lever; R1 would not have to unlock the door themselves. Based on this information, this allegaiton is deemed Unsubstantiated at this time. (continued on LIC9099-C) UnsubstantiatedRead the full finding— CDSS inspection report, March 20, 2025 · control 29-AS-20250311133256

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with administrator Jill Morris Chapman and explained the reason for the visit. On 08/29/2024, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint regarding neglect/lack of care and supervision. The complaint alleged that Resident #1 (R1) required medical attention due to staff’s failure to dispense prescribed seizure medication while in care of the facility. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Sonia Torre. (continued on page 2, LIC9099-C) SubstantiatedRead the full finding— CDSS inspection report, January 21, 2025 · control 29-AS-20240829092756

THIS IS AN AMENDED REPORT Licensing Program Analyst (LPA) Erika Miller (Miller) conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Jill Morris Chapman, Administrator and explained the purpose of the visit. Previously, Licensing Program Analyst (LPA) Christine Yee conducted an unannounced initial complaint visit to investigate the above allegations and met with Ashley Villarreal, Community Liaison. LPA Yee conducted an interview with Ashley Villarreal and collected relevant documentation. Allegation: It was alleged that there was a lack of supervision resulting in injury. Resident 1 (R1) was admitted to facility on 6/13/23 and admitted to hospice on 6/14/23. Based on the 6/16/23 incident report created by facility, R1 was found on the floor of their room at 8:30 a.m. and subsequently transported to hospital per family member request. R1 moved out of the facility on 6/19/23. Administrator advised that R1 did not return to Faciilty, as suchRead the full finding— CDSS inspection report, January 6, 2025 · control 29-AS-20230620161947

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial complaint visit was conducted on 04/26/2024 and a subsequent complaint visit was conducted on 05/22/2024, both by LPA M. Arroyo. On today's visit, LPA Arroyo met with Executive Director (ED), Jill Morris Chapman. Entrance interview. During the initial visit on 04/26/2024, LPA Arroyo conducted an interview with one (1) staff member at 10:12 a.m., conducted a resident file review at 10:45 a.m., and obtained copies of pertinent documents. On 05/22/2024, LPA Arroyo conducted interviews with one (1) staff, four (4) randomly selected residents, and two (2) randomly selected residents’ responsible person between 11:23 a.m. and 2:09 p.m. LPA also conducted a medication audit on two (2) randomly selected resident’s centrally stored medications between 2:10 p.m. and 3:30 p.m. and obtained copies of pertRead the full finding— CDSS inspection report, December 20, 2024 · control 29-AS-20240418165616

Licensing Program Analysts (LPA) Esther Cortez arrived at 10:10 a.m., unannounced to conduct a subsequent complaint visit. The LPA met with Executive Director Jill Morris Chapman and explained the reason for the visit. On 03/06/2023, LPAs Esther Cortez and Martha Arroyo conducted facility tour at 12:27pm, toured the kitchen and observed food supply at 12:32pm, conducted interviews with the interim executive director, two staff, and one resident between 12:27pm and 3:55pm. The LPAs also conducted a file review and obtained copies of resident files and other pertinent document revelant to the investigation at 1:15pm. On 03/15/2023 LPA Cortez and Teresa Camara interviewed (3) three residents at 10:04 a.m., 10:16 a.m., 11:08 a.m.; and, interviewed (3) three staff at 2:40 p.m., 2:44 p.m., and 3:34 p.m. On 09/19/2024 LPA Cortez toured the Kitchen, observed lunch in the dinining room, and interviewed six (6) residents,one (1) staff, and the Executive Director. During today's visit, LPA CortezRead the full finding— CDSS inspection report, September 30, 2024 · control 29-AS-20230301115936

Licensing Program Analyst (LPA) Kelly Dulek arrived unannounced to conduct a subsequent complaint visit. The LPA met with Marketing Director and explained the reason for the visit. Executive Director Jill Chapman was unavailable during today's visit. Entrance interview conducted. During today's visit, LPA obtained additional records and conducted a brief tour of the facility. During an initial complaint visit conducted on 02/06/2023, the LPA conducted an interview with Community Liason Director Ashley Villareal at 10:55AM, the LPA reviewed and obtained copies of pertinent documents, toured the facility along with Ashley Villareal at 11:18AM, viewed lunch service at 11:36AM, and conducted interviews with residents and staff from 11:38AM to 4:00PM. No health and safety hazards were identified during the visit. Throughout the course of the investigation, LPA reviewed relevant documents. The following was then determined: Report Continued on LIC 9099-C UnsubstantiatedRead the full finding— CDSS inspection report, August 22, 2024 · control 29-AS-20230201105127

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA Arroyo met with Executive Director, Jill Morris Chapman and explained the reason for the visit. On 10/20/2023, the Department received a complaint regarding an allegation of Neglect/Lack of Care and Supervision. It was alleged that facility staff failed to provide medication for Resident #1 (R1) which contributed to R1’s death. Concerns were that R1 was not receiving proper medications from the facility which caused a major stroke leading to death. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Laarni Santiago. Continued on LIC 9099C... UnsubstantiatedRead the full finding— CDSS inspection report, May 22, 2024 · control 29-AS-20231020083938

Licensing Program Analysts (LPA) Esther Cortez conducted an unannounced subsequent complaint visit for the above allegations. Upon arrival at 09:45 a.m., the LPA met with Family Advisor Ashley Villareal. Entrance interview conducted and the reason for the visit was explained. On 08/09/2023, between 8:45 a.m. and 3:45 p.m., the LPA toured the physical plant with Family Advisor Ashley Villareal, obtained pertinent documents, interviewed five (5) residents, and eight (8) staff. During today’s visit, LPA Cortez along with Family Advisor Ashley Villareal toured the facility at 10:30 a.m. The LPA also conducted interviews with residents approximately between 11:00 a.m. and 12:00 p.m.; interviews with staff were conducted approximately between 12:20 p.m. and 2:30 p.m. The LPA reviewed and obtained pertinent documents at approximately 2:30 p.m. Report will continue on LIC9099-C UnsubstantiatedRead the full finding— CDSS inspection report, August 25, 2023 · control 29-AS-20230803133832

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint visit to the facility at 08:30 a.m. to deliver the findings for the above allegation. The LPA met with Ashley Villareal, Family advisor, and the reason for the visit was explained. Wellness Director Justin Ramirez arrived shortly after. During the initial visit on 7/20/2023, between 1:20 p.m. and 3:00 p.m., the LPA toured the physical plant with administrator Joanna, obtained pertinent documents, interviewed two (2) staff and the administrator. Report will continue on LIC9099-C Unsubstantiated— CDSS inspection report, August 9, 2023 · control 29-AS-20230714150808

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 05/24/2021 by LPAs K. Dulek and M. Guzman Chavez and a subsequent visit was conducted on 03/01/2023 by LPA Arroyo. On today’s visit, LPA Arroyo met with the Business Office Manager, Mayra Gutierrez and the reason for the visit was explained. Entrance interview. During the initial visit on 05/24/2021, LPAs Dulek and Guzman Chavez conducted interviews with the Operations and Marketing Director and Wellness Director at 1:26 p.m. LPAs conducted a physical plant tour at 1:49 p.m., a kitchen and dining area tour at 2:05 p.m., conducted resident interviews between 2:52 p.m. and 3:25 p.m., and obtained copies of documents pertinent to the investigation. On 03/01/2023, LPA Arroyo conducted interviews with six staff and five residents between 12:15 p.m. and 1:55 p.m. and conductedRead the full finding— CDSS inspection report, July 27, 2023 · control 29-AS-20210521142052

Licensing Program Analysts (LPAs) Teresa Camara and Esther Cortez conducted a subsequent complaint visit. LPAs initially met with Community Liaison Director Ashley Villarreal at 9:42 a.m. and later met with Executive Director Sanjuana "Joanna" Enriquez at 11:55 a.m. and explained the reason for the visit to both. On 05/09/2022, the Department received a complaint alleging the facility staff failed to keep resident 1 (R1) safe. Specifically the complaint alleged that R1 was assaulted on the elevator by resident 2 (R2) on or about 4/5/2022. Resident 3 (R3) was also on the elevator during the incident. (continued on 9099-C) UnsubstantiatedRead the full finding— CDSS inspection report, March 15, 2023 · control 29-AS-20220509152612

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a subsequent visit. The LPA met with Sanjuana Enriquez and explained the reason for the visit. During the initial visit on 07/27/2022, the LPA met with Clinical Resource Martha Reynolds. On 07/27/2022, the LPA conducted a medication audit intermittently from 10:10 a.m. - 12:30 p.m., and interviewed staff at 9:50 a.m., 11:25 a.m., 11:30 a.m. and 2:25 p.m. The LPA also reviewed and obtained documents, and interviewed a resident responsible party at 12:17 p.m., and a private nurse at 12:25 p.m. On 02/17/2023, the LPA toured the facility, obtained documents, interviewed four (4) staff from 10:10 a.m. - 11:00 a.m., and interviewed ten (10) residents from 11:30 a.m. - 1:30 p.m. An interview was attempted with Resident #1 (R1) on 2/17/2023 at 9:40 a.m., and the LPA obtained hospice records for R1 and Resident #2 (R2). Today, the LPA interviewed staff at 9:45 a.m. and 9:55 a.m. SubstantiatedRead the full finding— CDSS inspection report, February 21, 2023 · control 29-AS-20220726081704

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Community Liason Director Ashley Villarreal and explained the reason for the visit. On 11/28/2022, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that facility staff failed to provide supervision resulting in Resident #1 (R1) sexually assaulting Resident #2 (R2). The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Christine Ferris. On 11/29/2022, from 11:32am to 1:10pm, Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced initial complaint visit. LPA Dulek met with Eric Terrill, Executive Director (ED), and explained the reason for the visit. During the visit, the LPA conducted an interview with the ED at Report Continued on LIC 9099-C UnsubstantiatedRead the full finding— CDSS inspection report, February 6, 2023 · control 29-AS-20221128165048