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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565800476
Report Date: 04/22/2025
Date Signed: 04/23/2025 09:05:13 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
12/27/2024 and conducted by Evaluator Valeria Conway
COMPLAINT CONTROL NUMBER: 29-AS-20241227114635
FACILITY NAME:ATRIA LAS POSASFACILITY NUMBER:
565800476
ADMINISTRATOR:ROMAN SIERRA TOVARFACILITY TYPE:
740
ADDRESS:24 LAS POSAS RDTELEPHONE:
(805) 987-9872
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:140CENSUS: 112DATE:
04/22/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Amber WintersteinTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Due to insufficient staffing, residents are not given medication as prescribed.
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 Winterstain. 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:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
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)
Page: 1 of 5
Control Number 29-AS-20241227114635
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:

Regarding allegation “Due to insufficient staffing, residents are not given medication as prescribed”. It was alleged that staff are either administering medication late or missing dosages entirely as a result of ongoing staffing shortage. During interviews, the ED acknowledged that the facility has experienced staffing challenges; however, the ED emphasized that the facility maintains adequate staffing levels to compensate for employees who resign or call out due to illness. Furthermore, the ED stated that medication administration remains a top priority for the facility, and staff are committed to ensuring medications are distributed on time. The ED also reported that no complaints have been received from residents regarding delayed or missed medication doses. Med-Techs interviewed stated that the staffing shortages have been an ongoing issue for the past few months. However, they affirmed that all medications has been administered at the prescribed times and no dosages have been missed. Interviews with residents revealed that staffing deficits have directly impacted the quality 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. 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 living unit. Furthermore, 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
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
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: 2 of 5
Control Number 29-AS-20241227114635
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 shortage of staff is causing medication issues. Therefore, the above allegation “insufficient staffing” is deemed SUBSTANTIATED at this time.

Medication’s concern will be addressed under a separate complaint, referenced by complaint #29-AS-20250318091807.

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.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
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: 3 of 5
Control Number 29-AS-20241227114635
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)
Request Denied
Type B
05/06/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements General (a) Facility personnel shall at all times be sufficient in numbers... In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure...This requirement is not met as evidenced by…
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Executive Director agreed to write a statement of understanding reg 87411, hire additional staff using an agency if necessary, submit a plan of action and ensure 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.
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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.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
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)
Page: 4 of 5