Office review·August 21, 2025

On 08/21/2025, an Informal Conference was held at the Woodland Hills North Adult and Senior Care Regional Office. In attendance included Licensing Program Manager (LPM) Kristin Heffernan, Licensing Program Analyst (LPA) Kelly Dulek, Administrator SanJuana “Joanna” Enriquez, Clinical Director David Rivas, RN, Market Leader Ann Margaret Zavela, RN, Interim Executive Director (ED) Monica Guardian, and Clinical Market Leader Roanne de los Reyes. The purpose of this Informal Conference is to discuss complaint investigation 29-AS-20240829092756 and a self-reported altercation that occurred on 08/05/2025 between a resident and staff. Prior to the start of the Informal Conference, the Licensee was given the opportunity to review the Community Care Licensing (CCL) file for Lexington Assisted Living (565850111), containing licensing reports for the past three years. The facility was licensed on 11/30/2020 and the current census is 69. On 08/29/2024, the RO received a complaint with allegations that included a questionable death, medications not being given as prescribed, and a resident’s room left unkempt. The investigation was referred to the Department’s Investigations Branch, and it was concluded that Resident #1 (R1) was not given their seizure medication during the approximate 10 days that R1 resided at the facility. As a result, R1 suffered a seizure on 08/13/2024, that required hospitalization. While hospitalized, R1 suffered a second, fatal seizure and expired on 08/20/2024. However, due to R1’s previous diagnosis, the facility was not found liable for R1’s death. The physical plant allegation of an unkempt room was also unsubstantiated. Report Continued on LIC 809-C During today’s conference, the licensee stated they have since augmented their intake procedures to include immediately logging all medications received into the facility’s centrally stored medication record. Additionally, facility staff review what medications are received upon move in and cross-reference a medication list the resident’s physician has signed to ensure all medications are received and can be administered as prescribed. In addition, on 08/05/2025, the RO received an incident report detailing a verbal altercation that took place between multiple staff members and R2. Subsequently, one staff sought medical treatment after the incident and was put on medical leave. Clinical Director explained the situation with R2 and the staff and steps that have been taken since the date of the incident. Staff have been attempting to redirect R2 and using additional de-escalation techniques. Training will be conducted with staff on Thursday 08/28/2025 to address concerns raised during this incident. Training will also be provided to all new incoming staff. Proof of training will be sent to CCL upon completion. Exit interview conducted and copy of today's report was provided to the licensee representatives.