565800476-4-23-2025-29-AS-KHEN-DH6V8P-20250530161303

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565800476
Report Date: 04/22/2025
Date Signed: 04/23/2025 09:06:30 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/18/2025 and conducted by Evaluator Valeria Conway

COMPLAINT CONTROL NUMBER: 29-AS-20250318091807

FACILITY NAME:	ATRIA LAS POSAS		FACILITY NUMBER:	565800476
ADMINISTRATOR:	AMBER WINTERSTEIN		FACILITY TYPE:	740
ADDRESS:	24 LAS POSAS RD		TELEPHONE:	(805) 987-9872
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	140	CENSUS: 112	DATE:	04/22/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Amber Winterstein		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not refill residents medication timely resulting in resident missing medications
Staff are not giving residents medication as prescribed
Insufficient staffing

INVESTIGATION FINDINGS:

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At 9:45 A.M. Licensing Program Analyst (LPA) Valeria Conway conducted a subsequent complaint visit with the purpose of delivering findings for the above listed allegations. LPA met with Executive Director (ED), Amber Winterstein. Reason for the visit was stated. Entrance interview conducted.

During today’s visit a brief physical plant tour was conducted. No health and safety concerns were identified during today's tour.

LPA Conway conducted an initial complaint visit on 03/20/2025. During that visit, LPA conducted a tour of the physical plant, Between 1:20 P.M. and 3:10 P.M. LPA conducted interviews with the ED, Resident Services Director (RSD) and two (2) staff members. Additionally, LPA obtained copies of pertinent documents relevant to the investigation and conducted a brief medication audit.

Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250318091807

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ATRIA LAS POSAS	FACILITY NUMBER: 565800476
	VISIT DATE: 04/22/2025

NARRATIVE

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Continued from LIC 9099

Throughout the course of the investigation, LPA reviewed all documents obtained and conducted telephonic interviews with additional credible witnesses and other relevant parties. The following was then determined:

As to the allegation of, staff did not refill resident’s medication timely resulting in resident missing medication and staff are not giving residents medication as prescribed. It was alleged that, due to staff neglect and workload, Resident #1 (R1) ran out of blood thinner, eyedrops and bone density medication, leading to a two-day lapse in medication administration. Interviews with ED and RSD revealed that for residents who are unable to manage their own medications, the facility stores their medication in the Med-Room. Medication Technicians (Med-Techs) and nurses are jointly responsible for ensuring medication refills are processed in a timely manner. According to facility protocol, refill requests for external pharmacies are to be faxed 27 days in advanced, while those using the facility’s preferred pharmacy must be requested at least 14 days in advance. Interviews with R1 revealed that although the resident is able to communicate their needs clearly and follow instruction, they are not capable of independently managing or administering their prescribed medications. The investigation confirmed that a lapse in medication occurred because staff failed to send a refill request to the pharmacy in time. It was discovered through interviews that neither the Med-Techs, nor the RSD adhere to physician’s instructions regarding timely medication refills. As a result, of the failure to timely refill prescriptions, R1 missed scheduled daily doses of prescribed medication. During interviews, a Med-Tech revealed that the nurse on duty had verbally assumed responsibility for placing the refill order. However, upon request by the LPA, no written documentation could be produced to verify that the nurse or any other trained staff had faxed, emailed or otherwise contacted the pharmacy prior to the depletion of R1’s medication supply. Medication audits were conducted on 12/31/2024, 03/20/2025 and 04/10/2025. During these audits, pill counts, Medication Administration Record (MAR) and Centrally Stored Medication and Destruction Record (CSMDR) were reviewed for ten (10) randomly selected residents.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250318091807

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ATRIA LAS POSAS	FACILITY NUMBER: 565800476
	VISIT DATE: 04/22/2025

NARRATIVE

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Continued from LIC 9099-C

The LPA found discrepancies in eight (8) out of ten (10) resident’s medication, where the pill counts within bubble packs did not match the records documented on the CSMDR. Morning Med-Techs on duty were unaware if these discrepancies, while evening med techs reported uncertainty about how these errors occurred, stating that often there is a breakdown in communication, documentation and medication administration between shifts. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that staff are not refilling resident’s medication in a timely manner. Therefore, the above allegation “staff did not refill resident’s medication timely resulting in resident missing medication and staff are not giving residents medication as prescribed,” is deemed SUBSTANTIATED at this time.

As to the allegation of insufficient staffing. It was alleged that a decline in staff morale from management, has contributed to an increase in staff resignations. As a result, ongoing staff shortages have been reported. Interviews with ED confirmed that the facility has experienced staffing challenges. However, the ED stated that the facility maintains sufficient staffing levels to cover for employees who resign or call out due to illness. Furthermore, the ED explained that both the Resident Care Coordinator and the Resident Service Director are qualified to performed Med-Techs duties and are available to provide coverage when needed. In addition, most Med-Techs are cross-trained in caregiving responsibilities and can be scheduled to assist on the floor as necessary to ensure continuity of care. Residents interviewed stated that staffing deficits have directly impacted the quality and timeliness of care provided to them. Specifically, concerns have been raised regarding delays in medication management, including missed or late medication administration, as well as extended wait times for resident assistance. Interviews with staff revealed ongoing concerns related to workload and staffing levels. Staff reported feeling overworked, stressed, and overwhelmed due to persistent staffing shortages. They indicated that they are frequently required to assume additional responsibilities and take on extra shifts, often with little advanced notice from management. Additional information provided by staff to the LPA indicated that occasionally a single staff member is assigned to cover all 3 floors of the Assisted Living unit. Staff reported that this level of understaffing has led to them rushing through tasks leading to careless errors related to medication administration, missing timelines, delays in assisting residents, and longer response times to resident call signals.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250318091807

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ATRIA LAS POSAS	FACILITY NUMBER: 565800476
	VISIT DATE: 04/22/2025

NARRATIVE

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Continued from LIC 9099-C

To further investigate these concerns, LPA conducted a comparison of staff schedules, timecards, and personnel reports (LIC 500). The review confirmed that facility has occasionally employees calling out of their schedule. Also, multiple employees are no longer working at the facility, resulting in other staff members being required to work double shifts. In certain instances, employees were asked to report to work on their scheduled days off to ensure adequate coverage. Additionally, the LPA observed staffing gaps during shifts, with only one (1) caregiver and one (1) Med-Tech on duty to provide care for all residents in the assisted licing unit. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that shortage of staff is causing medication issues and longer wait times. Therefore, the above allegation “insufficient staffing” is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20250318091807

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ATRIA LAS POSAS	FACILITY NUMBER: 565800476
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/25/2025 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465(a)(4)Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4)The licensee shall assist residents with sel-administered medications as needed. This requirement is not met as evidenced by…	1 2 3 4 5 6 7	ED will schedule a third party medication training for all med-techs that includes documentation and medication distribution and submit proof of scheduled session and completion to CCLD no later than POC due date.
	8 9 10 11 12 13 14	Based on interviews and record review the Executive Director did not comply with the regulation above by not ensuring medications are giving on a regular basis to residents in care which poses a potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 05/06/2025 Section Cited HSC 1569.618(c)(2)	1 2 3 4 5 6 7	Administration and management of residential care facilities; substituted qualifications; employee scheduling (c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (2) Ensure the health, safety, comfort, and supervision of the residents. This requirement is not met as evidenced by…	1 2 3 4 5 6 7	ED agreed to write a statement of understanding reg 87411, hire additional staff using an agency if necessary, submit a plan of action and ensure that staff are not taking lunch at the same time to have more staff on the floor during challenging times and send to LPA before POC due date.
	8 9 10 11 12 13 14	Based on interviews and record review the Executive Director did not comply with the regulation above by not having sufficient support staff to perform essential duties for residents in care which poses a potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

LIC9099 (FAS) - (06/04)

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