565800476-10-4-2024-29-AS-DPEA-DAGSVH-20241028141244

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565800476
Report Date: 10/04/2024
Date Signed: 10/04/2024 01:43:42 PM

Unsubstantiated

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
04/26/2024 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20240426151300

FACILITY NAME:	ATRIA LAS POSAS		FACILITY NUMBER:	565800476
ADMINISTRATOR:	ROBLOE BABASANTA		FACILITY TYPE:	740
ADDRESS:	24 LAS POSAS RD		TELEPHONE:	(805) 987-9872
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	140	CENSUS: 119	DATE:	10/04/2024
		UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Amber Winterstein		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Neglect/Lack of Care and Supervision: Resident #1 (R1) sustained a fracture/serious bodily injury while under the care and supervision of the facility.
Neglect/Lack of Care and Supervision: Resident #1 (1) was on the floor from an unwitnessed fall for an extended period of time while under the care and supervision of the facility.
Staff did not follow resident's care plan.
Staff went through resident's personal belongings without resident's consent.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA Camara met with Administrator/Executive Director (ED) Amber Winterstein and explained the reason for the visit. LPA also met with the resident services director at 11:06 a.m. and reviewed documents.

On 04/29/2024, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint regarding neglect/lack of care and supervision. The complaint alleged Resident #1 (R1) sustained a fracture while under the care and supervision of the facility, and facility staff left R1 on the floor for an extended period of time. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Jasmin Mendez.

(continued on LIC9099-C, page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

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 4

Control Number 29-AS-20240426151300

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: 10/04/2024

NARRATIVE

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(continued from LIC9099, page 1)

On 04/29/2024, from 2:47 p.m. to 4:10 p.m., LPA Kelly Dulek conducted an unannounced initial 10-day complaint visit. Beginning at 3:36 p.m., the LPA along with the ED toured the facility. No immediate health and safety concerns were identified during the tour. Additionally, the LPA reviewed and obtained copies of pertinent documents.

On 05/09/2024, from approximately 11:00 a.m. to 1:00 p.m., IB Investigators Mendez and Zertuche conducted interviews with R1’s resident representative, the facility ED, staff and attempted resident interviews however, due to dementia and mental capacity were unable to obtain resident interviews; and on 06/13/2024, from approximately 12:00 p.m. to 1:30 p.m., with Staff #1 (S1), med tech, and the Resident Services Director. In addition, the investigator reviewed Los Robles Regional Medical Center medical records, Ventura County Sheriff’s Office (VCSO) report #2024-51195, Ventura County Fire Department (VCFD) paramedics report, and video footage of R1’s room for 04/24/2024 and 04/25/2024, and the facility Weekly Schedule and Personnel Report.

Video footage was obtained from a surveillance camera placed inside R1’s room by R1’s resident representative. The video footage included footage from 04/24/2024 and 04/25/2024, which showed 1-minute videos for each hour of the day of R1’s room. The Department’s review of the video footage of R1’s room, showed a caregiver perform at least one quick room check during the night while R1 slept. R1 was seen walking to the bathroom a couple of times on their own and changing their own underwear without any assistance. R1 was not observed using their walker in both instances. At 4:09 a.m., staff checked on R1 and observed R1 asleep, so they did not disturb R1. At approximately 4:30 a.m., staff heard a loud yell asking for help coming from R1’s room. At approximately 4:32 a.m. staff entered R1’s room and discovered R1 on the ground in front of the television. The facility staff contacted the medical technician to call 911 for transfer. The video footage showed a caregiver act immediately by calling paramedics within two minutes. Paramedics arrived on scene within 15 minutes.

(continued on LIC9099-C, page 3)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20240426151300

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: 10/04/2024

NARRATIVE

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(continued from LIC9099-C, page 2)

On 04/25/2024, R1 was transported to Los Robles Regional Medical Center. The medical records documented R1 had a history of hypertension, hypothyroidism, and dementia. The records noted R1 got out of bed, tripped, and sustained a ground level fall. Caregivers found R1 on the floor. R1 normally used a walker to ambulate. There was no head strike or loss of consciousness. CT head scan was negative for any acute intracranial bleed. X-Rays demonstrated a “moderately communicated and moderate severely displaced obliquely oriented fracture of the right femoral shaft”.

A review of the VCSO report 2024-51195 revealed that based on the information the VCSO observed in the video for R1’s accidental unwitnessed fall, the staff member tended to R1 in a timely manner. The VCSO was unable to prove a crime had occurred. No arrests were made, and the case was closed.

On the allegation “Neglect/Lack of Care and Supervision: Resident #1 (R1) sustained a fracture/serious bodily injury while under the care and supervision of the facility” - On 04/25/2024, the day of the incident, R1 sustained an unwitnessed fall while residing at the facility. The facility staff conducted resident checks on 04/24/2024 at approximately 10:00 p.m. (start of shift for the night staff), and at 4:09 a.m. (based on video footage) on 04/25/2024 and noted R1 was still in bed for all checks. Video footage showed R1 getting up from bed and walking to the bathroom a couple of times during the night. Video footage, with limited view, showed staff opening the door at approximately 4:09 a.m. and peaking quickly inside to see if R1 was sleeping. This room check lasted approximately three seconds. R1 was observed sleeping and staff closing the door after the room check. At approximately 4:30 a.m., staff heard a loud yell asking for help coming from R1’s room. At approximately 4:32 a.m., staff entered R1’s room and discovered R1 on the ground in front of the television. The facility staff contacted the medical technician to call 911 for transfer. The facility staff gave a pillow and blanket to R1 to make R1 comfortable while they waited for paramedics. Video footage and medical records from the Ventura County Fire Department (VCFD) show that at approximately 4:45 a.m. the paramedics arrived at the facility and transferred R1 to Los Robles Regional Medical Center. The video footage showed that facility staff briefly checked on R1, 21 minutes prior to R1’s fall. Based on the interviews conducted, records and video footage reviewed, the Department did not find sufficient evidence that the facility neglected the care of R1. Therefore, the allegation is deemed Unsubstantiated at this time.

(continued on LIC9099-C, page 4)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20240426151300

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: 10/04/2024

NARRATIVE

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(continued from LIC9099-C, page 3)

On the allegation “Neglect/Lack of Care and Supervision: Resident #1 (1) was on the floor from an unwitnessed fall for an extended period of time while under the care and supervision of the facility” – On 04/25/2024, the facility staff conducted round checks at approximately 4:09 a.m. and noted R1 was still in bed. At approximately 4:30 a.m. staff heard a loud yell asking for help coming from R1’s room. At approximately 4:32 a.m. staff went into R1’s room and discovered R1 on the ground in front of the television. The facility staff contacted the medical technician to call 911 for transfer. The facility staff gave a pillow and blanket to R1 to make R1 comfortable while they waited for paramedics. Video footage and medical records show that at approximately 4:45 a.m. the Ventura County Fire Department (VCFD) arrived at the facility and transferred R1 to Los Robles Regional Medical Center. Staff called for medical help within three minutes of discovering R1 on the floor and paramedics arrived within 15 minutes. Based on the interviews conducted, records and video footage reviewed, the Department did not find sufficient evidence that the facility failed to seek timely medical attention for R1. Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation "Staff did not follow resident's care plan" - LPA Camara reviewed R1's care plan as well as the resident assessment report for R1 on which facility staff notate when they perform required care as per the care plan. In addition, the investigator noted seeing facility staff on video quickly peeking into the room to see if R1 was still sleeping during the night of 4/25/2024. There was no indication facility staff were not following R1's care plan. Based on this information, this allegation is deemed Unsubstantiated at this time.

On the allegation "Staff went through resident's personal belongings without resident's consent" - The resident care director stated staff must go through drawers and other personal belongings to locate items needed to get a resident ready. Some residents, especially those in memory care, tend to move things around so staff must look for them. In R1's case, they wore hearing aids and frequently placed them in different locations including their purse. Neither the facility nor CCL ever received a report of missing items from R1's room. Based on this information, this allegation is deemed Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted and a copy of this report was issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

LIC9099 (FAS) - (06/04)

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