Atria Las Posas

Allegation investigated: Facility is not assisting residents with medical appointments

Licensing Program Analyst (LPA) Valeria Conway conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegation. At 12:00 LPA met with Monique Moreira, Executive Director and explained the purpose of the visit. Today, a brief tour was conducted. Throughout the course of the investigation, LPA conducted additional interviews and reviewed all documents obtained. The following was determined: Regarding the allegation of “Facility is not assisting residents with medical appointments” it was the Reporting Party’s (RP’s) concern that facility staff did not schedule a dermatology appointment for Resident #1 (R1). R1 resides in a memory care unit and requires assistance from facility staff and family members to coordinate medical appointments. Continued on LIC 9099-C Unsubstantiated Continued from LIC 9099 Interviews with facility staff confirmed that a dermatology appointment was scheduled and that a family member transported R1 to the appointment in April 2026. However, R1 refused to see a dermatologist to have their skin examined and was returned to the facility. Adding that to prevent trauma transfer, facility offered R1’s family to arrange a nurse practitioner to assess and provide wound care to R1 at the facility. R1’s Family Members (FM) stated that facility staff and home health nurses notified them of R1’s skin condition and they immediately scheduled a dermatologist appointment, however, R1 got agitated and refused to see the Dr. On 08/06/2026, R1's physician discussed a dermatology referral; however, R1's FM declined to proceed with the referral. FM understands that the skin lesion could worsen if it is not treated and other options are being discussed with facility staff. FM is satisfied with services provided to R1 and denied ever having a problem with Drs. appointments. Records reviewed established that facility staff communicated with R1’s family regarding R1’s dermatological condition and assisted in coordinating a dermatology appointment. As of 08/27/2026, R1 is receiving hospice services, and hospice nurses visiting R1 are providing wound care. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Facility is not assisting resident with medical appointments” is deemed Unsubstantiated at this time. No citations issued. Exit interview conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 23, 2026 · control 29-AS-20260618142925

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Valeria Conway and Martha Arroyo arrived at the facility at 9:30 A.M., for an unannounced required annual inspection. LPAs met with Executive Director, Kenneth “Ken” Mahler and discussed the reason for the visit. Entrance interview conducted. Beginning at 9:40 A.M., the LPAs along with the ED and the Maintenance Technician, Daniel Mitchell, toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The facility is a two-story and ground floor building. The following was observed: A fire alarm inspection was conducted by Johnson Controls Fire Protection on 05/20/2026, all deficiencies noted on report were repaired and/or corrected. Several fire extinguishers throughout the building were observed to be fully charged and last serviced on 10/11/2025. At 9:45 A.M., carbon monoxide alarm was tested and properly functioned at the time of the visit. RESIDENT ROOMS/RESTROOMS: A random selection of 9 (nine) resident rooms in the assisted living side and two (2) random resident rooms in the Life Guidance (Memory Care) were observed. All resident rooms were furnished appropriately, with clean linens and appropriate furnishings and were equipped with a refrigerator, sink, and microwave and contain private restrooms. The bathrooms were observed to be safe and sanitary with grab bars and slip-resistant surfaces and were sufficiently stocked with supplies and paper towels. Starting at 9:42 A.M., the hot water temperature was measured in all rooms inspected and was within the regulation range of 105-120 degrees Fahrenheit. Continued on LIC 809-C Continued from LIC 809 COMMON SPACES: In the common areas, walls, flooring, and furnishings were checked for cleanliness and good condition. Fireplaces were observed to be adequately screened. LPAs observed the required postings in the common hallway and throughout the building. All hallways and egresses were observed to be free of obstructions. The LPAs observed the stairwells, and they each had an emergency evacuation chair. KITCHEN: The main kitchen and dining room are located on the 2nd floor. Food is prepared in the main kitchen and delivered to the dining area and the Life Guidance (Memory Care) dining room. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. LPAs observed a minimum of two (2) days perishable and seven (7) days non-perishable foods. LPAs inspected refrigerator and pantry for expiration dates. Kitchen appliances were in operable condition. LPAs observed a sufficient supply of emergency food and water. All knives and cleaning supplies were observed to be properly stored at the time of the visit. OUTDOOR SPACES: The LPAs and ED toured the outside areas of the facility. The Assisted Living and Life Guidance contained 2 (two) courtyards for resident use. During today’s visit the LPAs observed three (3) operational water fountains on the promises. Two (2) fountains are located in the assisted living area and the other is situated within the Life Guidance unit. The LPAs observed appropriate outdoor furniture, with a covered shaded area for resident use. RECORD REVIEW: Starting at 11:30 A.M. ten (10) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. All records were in order. Ten (10) personnel files were reviewed for, but not limited to: personnel records, health assessments with TB results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All files were complete. Continued on LIC 809-C Continued from LIC 809-C MEDICATIONS: Medications for the Assisted Living Unit and the Life Guidance unit are centrally stored and locked in their medication room. Medication review began at 2:05 P.M. LPA Conway along with Gabrielle Richwine, audited the current prescribed medications for five (5) residents and compared the medications on hand with the Centrally Stored Medication and Destruction Record (LIC 622). LPA observed that some medications being dispensed to residents were not listed on the LIC 622. INTERVIEWS: Throughout today's visit, LPAs interviewed eight (8) residents and 4 (four) staff members. INFECTION CONTROL/EMERGENCY DISASTER: LPAs also reviewed the facility's Emergency Disaster Plan, which was observed to be complete and updated annually as required. Emergency Disaster drills are conducted quarterly, with the last drill documented on 03/01/2026. Daily vehicle inspection list, current registration, and insurance documentation for two (2) facility vehicles were reviewed. LPAs observed that the insurance coverage for both vehicles had expired on 06/01/2026. During today’s visit LPAs obtained a copy of the facility’s LIC 500, resident roster and liability insurance. Liability insurance provided had an expiration date of 06/01/2026. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-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.the state’s words, verbatim · CDSS document, Jun 8, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Valeria Conway and Martha Arroyo arrived at the facility at 9:30 A.M., for an unannounced required annual inspection. LPAs met with Executive Director, Kenneth “Ken” Mahler and discussed the reason for the visit. Entrance interview conducted. Beginning at 9:40 A.M., the LPAs along with the ED and the Maintenance Technician, Daniel Mitchell, toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The facility is a two-story and ground floor building. The following was observed: A fire alarm inspection was conducted by Johnson Controls Fire Protection on 05/20/2026, all deficiencies noted on report were repaired and/or corrected. Several fire extinguishers throughout the building were observed to be fully charged and last serviced on 10/11/2025. At 9:45 A.M., carbon monoxide alarm was tested and properly functioned at the time of the visit. RESIDENT ROOMS/RESTROOMS: A random selection of 9 (nine) resident rooms in the assisted living side and two (2) random resident rooms in the Life Guidance (Memory Care) were observed. All resident rooms were furnished appropriately, with clean linens and appropriate furnishings and were equipped with a refrigerator, sink, and microwave and contain private restrooms. The bathrooms were observed to be safe and sanitary with grab bars and slip-resistant surfaces and were sufficiently stocked with supplies and paper towels. Starting at 9:42 A.M., the hot water temperature was measured in all rooms inspected and was within the regulation range of 105-120 degrees Fahrenheit. Continued on LIC 809-C Continued from LIC 809 COMMON SPACES: In the common areas, walls, flooring, and furnishings were checked for cleanliness and good condition. Fireplaces were observed to be adequately screened. LPAs observed the required postings in the common hallway and throughout the building. All hallways and egresses were observed to be free of obstructions. The LPAs observed the stairwells, and they each had an emergency evacuation chair. KITCHEN: The main kitchen and dining room are located on the 2nd floor. Food is prepared in the main kitchen and delivered to the dining area and the Life Guidance (Memory Care) dining room. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. LPAs observed a minimum of two (2) days perishable and seven (7) days non-perishable foods. LPAs inspected refrigerator and pantry for expiration dates. Kitchen appliances were in operable condition. LPAs observed a sufficient supply of emergency food and water. All knives and cleaning supplies were observed to be properly stored at the time of the visit. OUTDOOR SPACES: The LPAs and ED toured the outside areas of the facility. The Assisted Living and Life Guidance contained 2 (two) courtyards for resident use. During today’s visit the LPAs observed three (3) operational water fountains on the promises. Two (2) fountains are located in the assisted living area and the other is situated within the Life Guidance unit. The LPAs observed appropriate outdoor furniture, with a covered shaded area for resident use. RECORD REVIEW: Starting at 11:30 A.M. ten (10) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. All records were in order. Ten (10) personnel files were reviewed for, but not limited to: personnel records, health assessments with TB results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All files were complete. Continued on LIC 809-C Continued from LIC 809-C MEDICATIONS: Medications for the Assisted Living Unit and the Life Guidance unit are centrally stored and locked in their medication room. Medication review began at 2:05 P.M. LPA Conway along with Gabrielle Richwine, audited the current prescribed medications for five (5) residents and compared the medications on hand with the Centrally Stored Medication and Destruction Record (LIC 622). LPA observed that some medications being dispensed to residents were not listed on the LIC 622. INTERVIEWS: Throughout today's visit, LPAs interviewed eight (8) residents and 4 (four) staff members. INFECTION CONTROL/EMERGENCY DISASTER: LPAs also reviewed the facility's Emergency Disaster Plan, which was observed to be complete and updated annually as required. Emergency Disaster drills are conducted quarterly, with the last drill documented on 03/01/2026. Daily vehicle inspection list, current registration, and insurance documentation for two (2) facility vehicles were reviewed. LPAs observed that the insurance coverage for both vehicles had expired on 06/01/2026. During today’s visit LPAs obtained a copy of the facility’s LIC 500, resident roster and liability insurance. Liability insurance provided had an expiration date of 06/01/2026. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-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.the state’s words, verbatim · CDSS document, Jun 8, 2026

Allegation investigated: Staff mismanaged resident's medication

Licensing Program Analyst (LPA) Valeria Conway conducted a subsequent complaint visit with the purpose of delivering findings for the above listed allegation. LPA arrived at the facility at 10:20 A.M. and met with front desk staff, who contacted the Resident Service Director (RSD), Natalie Ontiveros. At 10:32 A.M., RSD contacted Interim Executive Director (ED), Remon Pagels via telephone.4004 Interim ED was unavailable during today's visit, but authorized RSD to sign today's reports. The reason for the visit was stated. Entrance interview conducted. . Regarding the allegation “Staff mismanaged resident's medication”, it is the Reporting Parties (RPs) concern that staff are unable to manage a system to ensure there is an adequate supply of resident medication refills. Additionally, the RP further stated that staff do not follow orders when administrating medications to residents. Continued on LIC 9099-D Substantiated Continued from LIC 9099 During today’s visit a brief physical plant tour of the facility was conducted. On 10/27/2025 and 02/26/2026, LPA conducted interviews with interim ED, and three (3) Med-Techs and the Resident Service Director (RSD), Natalie Ontiveros. Additionally, LPA conducted a review of Resident #1's (R1's) file, obtained copies of pertinent documents relevant to the investigation, and conducted a medication audit. Information gathered reflected that R1 does not utilize the facility pharmacy and has Kaiser. Throughout the course of the investigation, LPA reviewed all documents obtained, conducted additional telephonic interviews with current and former residents and staff. The following was then determined: Interview with the management revealed that med techs are responsible for refilling, reordering and ensuring that residents’ medications are available at the facility before supplies are depleted. Additionally, it was noted that the community utilizes an electronic medication management system, Accuflow, which generates electronic Medication Administration Record (eMARs). These eMARs include resident information, medication details and administration schedules based on physicians’ orders. Moreover, information gathered reflected that facility utilizes Omnicare as the facility pharmacy and residents are highly encouraged to use the facility pharmacy to ensure faster service. Any resident that does not utilize the facility's pharmacy, including R1, must provide a signed and dated physician's order to the facility med-techs, who will then fax the information for entry into the Accuflow system, which can take up to 24 hours. However, based on facility policy, med-techs are not able to administer any medication until the information is reflected on Accuflow. Therefore, a resident's family/friend of needs to assist with storing the medication and support the resident with with self-administration during that time. Due to R1 not utilizing the community's pharmacy, R1 is expected to obtain the refill independently until the facility receives and documents the updated order in the electronic medication management system. Staff interviews also revealed inconsistent responses regarding medication management practices. Some staff reported no issues with dispensing or refilling medications prior to them running out. However, other staff stated they are often overwhelmed and overworked and indicated that incoming faxes with medication changes or refill requests may occasionally be overlooked, resulting in delays. Staff acknowledged that the facility has procedures in place to ensure timely medication refills, however, it is disregarded by some staff. Continued on LIC 9099-C Continued from LIC 9099-C Regarding the required five-minute interval between administering two (2) different medications, staff confirmed that the interval is not always observed and stated that, at times, medications are administered without waiting for the full five (5) minutes for convenience or to save time. LPA Conway conducted a medication audit and reviewed supporting documentation including but not limited to, Medication Administration Records (MAR), physician orders and the Centrally Stored Medication & Destruction Record (LIC 622) for R1. Record reviewed revealed the facility failed to properly administer at least two (2) mediations as prescribed. During the medication audit on 10/27/2025, LPA observed a faxed physician’s order dated 10/21/2025, directing that Fosamax be administered on Monday mornings instead of Sunday mornings. Review of the eMARs indicated the medication had been administered correctly prior to the change, however, after receipt of the updated order, the medication was administered on Sunday 10/26/2025 and not on Monday 10/27/2025 as prescribed. Additionally, review of medication records revealed discrepancies in documentation. The medication RX# on the open box label did not match the medication RX # recorded LIC 622. Further review of the physician’s order for Brimonidine Tartrate 0.2% indicated the medication was to be administered three (3) times daily. However, the MAR and Med Techs initials reflected the medication was administered only twice (2) daily (8 AM and 8 PM), rather than three (3) times daily as prescribed. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Staff mismanaged resident's medication” has been 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. LPA informed the RSD that this is a repeat violation of the same regulation within a twelve (12) month period. LPA informed the Administrator that a civil penalty in the amount of $250 is being assessed on today’s date (03/11/2026) for a repeat violation. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 11, 2026 · control 29-AS-20251020160401

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 12, 2026

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 self-administered medications as needed. This requirement is not met as evidenced by… Based on interviews and record reviews, the facility did not comply with the regulation above by not ensuring medications are given as prescribed by their physician to residents in care which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: Facility will retrain all med techs on the "triple-check" process and provide an in-service training on medication administrion basics including proper review of documents for accuracy.A written statement of understanding confirming the facility's plan to complete the required training will be submitted to the LPA before POC due date. Training sign-in sheets and inservice material will be submitted to LPA no later than 3/25/2026.

Allegation investigated: Staff did not treat residents with respect

Licensing Program Analyst (LPA) Valeria Conway conducted a 10-day initial complaint visit to address the allegation listed above. LPA arrived at the facility at 9:50 A.M. and met with front desk staff, who contacted the Resident Service Director (RSD), Natalie Ontiveros. RSD contacted Interim Executive Director (ED), Remon Pagels via telephone. At 10:08 A.M. Interim ED was unavailable during today's visit, but authorized RSD to sign today's reports. Entrance interview conducted. During today’s visit a brief physical plant tour of the facility was conducted. On 10/27/2025, LPA conducted interviews with interim ED, and three (3) Med-Techs. Additionally, LPA conducted a review of Resident #1's file, obtained copies of pertinent documents relevant to the investigation, and conducted a medication audit. Throughout the course of the investigation, LPA reviewed all documents obtained, conducted telephonic interviews with additional credible witnesses and other relevant parties. The following was then determined: Continued on LIC 9099-C Unsubstantiated Continued from LIC 9099 Regarding allegation “Staff did not treat residents with respect” the Reporting Party (RP) expressed concern that Staff #1 (S1) spoke to Resident #1 (R1) in a disrespectful manner, made uncomfortable remarks, and used R1’s ottoman while administering medication. An interview with R1 revealed that they generally has positive comments about the staff, with the exception of S1. R1 described S1 as having a lot of energy and being “an entertainer”, which at times made them feel uncomfortable. R1 also stated they did not like when S1 sat on their ottoman while administering eye drops. R1 reported that management addressed their concerns with S1 and, since that conversation, S1 has “toned down” their behavior and there have been no further issues. Interviews conducted with randomly selected residents indicated they feel respected by staff, have no concerns regarding the quality of care provided, and do not feel disrespected by any staff members. Additional residents stated that staff are kind, courteous, and have never made them feel uncomfortable. Interviews with staff, including S1, revealed that staff enjoy working at the facility. S1 denied speaking to residents in a disrespectful manner or making inappropriate remarks and stated that assistance and redirection are provided to residents as needed in a professional manner. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff did not treat residents with respect” is deemed UNSUBSTANTIATED at this time. No deficiency related to the allegations were cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Feb 26, 2026 · control 29-AS-20251020160401

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility failed to report an outbreak to appropriate agencies

This report has been amended to remove confidential information. Licensing Program Analyst (LPA) Valeria Conway conducted a 10-day initial complaint visit to address the allegation listed above. LPA arrived at the facility at 9:50 A.M. and met with front desk staff, who contacted the Resident Service Director (RSD), Natalie Ontiveros. RSD contacted Interim Executive Director (ED), Remon Pagels via telephone. At 10:08 A.M. Interim ED was unavailable during today's visit, but authorized RSD to sign today's reports. Entrance interview conducted. During today’s visit, LPA conducted additional interviews and reviewed facility records. LPA reviewed documentation including the Ventura County Public Health (VCPH) outbreak monitoring line lists, posted outbreak notifications, facility progress notes, incident reports submitted to Community Care Licensing (CCL), and email correspondence. The following was then determined: Continude on LIC 9099-C Substantiated Continued from LIC 9099 Regarding the allegation “Facility failed to report an outbreak to appropriate agencies” it is the Reporting Parties (RPs) concern that the facility failed to notify CCL and VCPH of an ongoing Gastrointestinal diseases (GI)/Norovirus outbreak. It was further reported that several residents and staff were exhibiting symptoms such as vomiting and diarrhea, and the facility was experiencing an outbreak approximately a week before appropriate agencies were involved. During the course of the investigation, LPA interviewed VCPH personnel who confirmed that the facility in fact did not report the outbreak to the agency. Interview conducted with ED revealed that physicians and resident’s responsible parties were informed of the symptoms, isolation measures, and outbreak status at the facility. The ED stated that beginning 02/18/2026, the dining and common areas were closed, in-room tray service was implemented, and all group activities were canceled until the outbreak was contained. The ED further stated that the facility has sufficient staff to care for residents during this outbreak, sufficient Personal Protective Equipment (PPE) and disinfectant supplies and that high-touch areas are being cleaned and disinfected frequently. Interviews with residents and staff revealed that GI symptoms had been circulating in the facility since the first week of February, when multiple residents and staff began experiencing symptoms. Residents reported that written notice of the outbreak was provided on 02/18/2026. Residents further stated that isolation protocols are in place, the dining room is closed, meals are being delivered to their rooms, and activities have been suspended until further notice. A review of the Serious Incident Reports (SIRs) submitted by the facility to CCL reflected that an SIR was submitted on 02/18/2026. The SIR confirmed the presence of an outbreak. Review of the facility’s line list revealed the between 02/05/2026 and 02/21/2026, a total of twenty-six (26) cases involving residents and staff were documented with symptoms of vomiting and diarrhea. Additionally, on 02/08/206, Resident #1 (R1) was hospitalized and upon discharge on 02/11/2026, was diagnosed with Norovirus. Although the facility implemented isolation precautions for symptomatic residents prior to receiving the confirmed diagnosis on 2/12/2026, the facility did not to notify CCL and the local health department within 24 hours of the initial onset of symptoms among residents and staff. Furthermore, the facility did not report the hospitalization of R1 within seven (7) days from the date of occurrence, as required by regulation. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Facility failed to report an outbreak to appropriate agencies” has been 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 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Amended report was discussed with administrator telephonically. A copy of the amended report and appeal rights were provided. Continued from LIC 9099-C Third page was intentionally left blank. A hard copy of this page was emailed for signature.the state’s words, verbatim · CDSS document, Feb 26, 2026 · control 29-AS-20260218095129

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a) · Plan of correction due date: Feb 27, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: This requirement is not met as evidenced by: Based on interview conducted and records reviewed, facility did not comply with the section cited above as they did not submit an outbreak incident report within 24 hours and an incident report for R1’s hospitalization within 7 days which poses an immediate health and safety risk to resident (s) in care.the state’s words, verbatim · CDSS document, Feb 26, 2026

Plan of correction: ED or designee agreed to write a statement of understanding on regulation 87211, submit a new infection control plan and pending incidents to LPA before PCO due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced Case Management Deficiency visit in conjunction with an initial 10-day complaint visit (CC #29-AS-20251020160401). LPA met with interim Executive Director (ED), Remon Pagels. The purpose of this report is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. Woodland Hills Regional Office received an email on 10/26/2025, notifying that a change of Administrator/ED for Atria Las Posas was effective 10/11/2025. The email included attachments containing the new interim ED's information and the required supporting documents. During today's visit, LPA reviewed the Guardian System, which reflected that the new Administrator is fingerprint cleared; however, they are not associated with the facility as of today. An immediate civil penalty of $500 for back ground check - Association transfer violation is assessed today. Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D) Exit interview conducted. Citations issued. A Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 27, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Oct 28, 2025

Criminal Record Clearance. (e) All individuals subject to a criminal record review ... shall prior to working, residing, or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance...This requirement is not met as evidenced by: Based on record review, and interviews, licensee did not comply with the above section by not ensuring the new Administrator had fingerprint association transferred to the facility prior working, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 27, 2025

Plan of correction: Licensee agreed to update the Guardian System associating the new administrator to this facility and submit proof by POC due date.

Allegation investigated: Insufficient staffing

Licensing Program Analyst (LPA) Valeria Conway conducted a subsequent complaint visit with the purpose of delivering findings for the above listed allegation. LPA met with Executive Director (ED), Amber Winterstein. The reason for the visit was stated. Entrance interview conducted. During today’s visit a brief physical plant tour of the facility was conducted to ensure health and safety precautions were met. No immediate health and safety concerns were identified during today's visit. On 07/03/2025, LPA interviewed the ED and conducted a physical plant tour, including the Life Guidance/Memory Care (LG) unit. LPA obtained copies of documents pertinent to the investigation, reviewed resident files and requested timecards and schedules for all current staff. Continued on LIC 9099-C Substantiated Continued from LIC 9099 It was alleged that the facility is understaffed and that residents’ needs are not being met in the LG unit. The complainant expressed concern that they believe the staff to resident ratio is poor or inadequate and stated that between the hours of 2:00 PM and 10:00 PM there is no staff available to assist confused residents in the LG unit who required redirection. An interview conducted on 07/3/2025, with the ED revealed that management is making efforts to keep the facility fully staffed. The ED stated that the facility schedules three (3) caregivers, two (2) med-techs and a Director in the Assisted Living (AL) unit during the AM and two (2) caregivers and two (2) med-techs in the PM. In the LG unit staff are scheduled as follows three (3) caregivers, one (1) med-tech during the morning (AM), an activity coordinator and a Director and two (2) caregivers and one (1) med-tech during afternoon (PM) shifts in the LG unit. Residents interviewed indicated that staffing levels vary from day to day; however, residents generally reported that the facility often lacks sufficient caregivers, resulting in long wait when assistance is needed. Staff interviews revealed that staff feel overworked and reported that are often not enough personnel to meet residents’ needs due to insufficient scheduling, approved time off and call-outs. Staff further disclosed that caregivers are frequently “pulled” from one unit to cover the other, leaving both units short-staffed. Additionally, staff reported that residents are occasionally left unattended for short periods when caregivers are assisting residents who wander, attempt to exit the building, or require temporary two (2) person assistance. Other credible witnesses also reported observing only one caregiver on the floor while the med-tech was on lunch break (and vice versa) and further disclosed that family members have occasionally offered to assist in serving meals in the LG unit due to staff shortages. LPA reviewed timecards and schedules for the LG unit dated June 21-23, 2025, and June 27-28, 2025. The review revealed the following: On Sunday June 22, the LG unit schedule reflected one (1) caregiver and one (1) med-tech for the entire day. On Monday June 23 (AM shift), the schedule reflected one (1) caregiver, and one (1) med-tech. Timecards also showed that staff did not take a lunch break during this shift and that the activity coordinator is scheduled off on Sundays and Mondays. On Friday June 27th and Saturday June 28th, some caregivers were scheduled for double shifts (6:00 AM-6:00 PM and 5:00 PM to 5:00 AM). In addition, one caregiver was left alone on the floor for approximately two and a half (2 ½) hours during a shift change. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that facility is understaffed in the LG unit. Therefore, the above allegation “Insufficient staffing” is deemed SUBSTANTIATED at this time. Continued on LIC 9099-C Continued from LIC 9099-C Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. An immediate civil penalty of $250 repeat violation is assessed today due to being cited for the same violation within 12 months. Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 18, 2025 · control 29-AS-20250625091704

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Sep 18, 2025

87411(a) 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… Based on interviews and record reviews the Executive Director did not comply with the regulation above by not having sufficient support for staff to perform essential duties for residents in care which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 18, 2025

Plan of correction: The Executive Director agreed to write a statement of understanding reg 87411(a). Schedule at least 2 caregivers and at least 1 med tech and submit these to LPA before POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Valeria Conway and Martha Arroyo arrived at the facility at 9:15 A.M., for an unannounced required annual inspection. LPAs met with Executive Director, Amber Winterstein and discussed the reason for the visit. Entrance interview conducted. Beginning at 10:30 A.M., the LPAs along with the ED, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is a two-story and a ground floor building. The following was observed: According to the maintenance director batteries in the smoke detectors are changed once a year. 5-Year fire sprinkler inspection was conducted by Johnson Controls Fire Protection on 02/25/2022, all deficiencies noted on report were repaired and/or corrected by 04/22/2022. No safety concerns were noted at that time. Several fire extinguishers throughout the building were observed to be fully charged and last serviced on 08/30/2024. At 11:21 A.M., carbon monoxide alarm was tested and properly functioned at the time of the visit. Continued on LIC 809-C Continued from LIC 809 KITCHEN: The main kitchen and dining room are located on the 2nd floor. Food is prepared in the main kitchen and delivered to the dining area and the Life Guidance (Memory Care) dining room. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. LPAs observed a minimum of two (2) days perishable and seven (7) days non-perishable foods. LPAs inspected refrigerator and pantry for expiration dates. Kitchen appliances were in operable condition. LPAs observed a sufficient supply of emergency food and water. All knives and cleaning supplies were observed to be properly stored at the time of the visit. RESIDENT ROOMS/RESTROOMS: A random selection of 6 (six) resident rooms in the assisted living side and five (5) random resident rooms in the Life Guidance (Memory Care) were observed. All resident rooms were furnished appropriately, with clean linens and appropriate furnishings and were equipped with a refrigerator, sink, and microwave and contain private restrooms. The bathrooms were observed to be safe and sanitary with grab bars and slip-resistant surfaces and were sufficiently stocked with supplies and paper towels. Starting at 10:34 A.M., the hot water temperature was measured in all rooms inspected. Hot water in four (4) out the eleven (11) rooms checked were above the required range. Maintenance director adjusted the water heater temperature during the visit. Technical violation (TV) issued. During today’s visit, LPAs observed the facility’s response system procedures in the Life Guidance unit. It was noted that staff utilize pagers to respond to residents when assistance is requested via push alert button located in their rooms. While testing the auditory signal system, it was observed that two (2) staff members assigned to the floor did not have their pagers with them and were not aware that the call system was activated for testing. When questioned, the staff stated that the pagers were not functioning due to low battery issues. Maintenance director was informed and replaced malfunctioning pagers with new ones. During today’s visit the new pagers were tested and functioning. Continued on LIC 809-C Continued from LIC 809-C OUTDOOR SPACES: The LPAs and ED toured the outside areas of the facility. The Assisted Living and Life Guidance contained 2 (two) courtyards for resident use. During today’s visit the LPAs observed three (3) operational water fountains on the promises. Two (2) fountains are located in the assisted living area and the other is situated within the Life Guidance unit. The LPAs observed appropriate outdoor furniture, with a covered shaded area for resident use. RECORD REVIEW: Starting at 12:29 P.M ten resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. All records were in order. Ten personnel files were reviewed for, but not limited to: personnel records, health assessments with TB results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All files were complete. MEDICATIONS: Medications for the Assisted Living Unit and the Life Guidance unit are centrally stored and locked in their medication room. Medication review began at 2:05 P.M. LPAs observed medications for five (5) residents. All medications observed were stored in compliance with regulation, however, during medication audit it was revealed that two (2) out of five (5) centrally stored medication start date did not match what was recorded on the centrally store medication and destruction record. Technical advisory (TA) issued. INTERVIEWS: Throughout today's visit, LPAs interviewed 3 (three) residents and 4 (four) staff members. Continued on LIC 809-C Continued from LIC 809-C INFECTION CONTROL/EMERGENCY DISASTER: LPAs also reviewed the facility's Emergency Disaster Plan, which was observed to be complete and updated annually as required. Emergency Disaster drills are conducted monthly, with the last drill documented on 05/21/2025. Daily vehicle inspection list, current registration, and insurance was reviewed for facility vehicle. During today’s visit LPAs obtained a copy of the facility’s LIC 500, resident roster and current liability insurance. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-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.the state’s words, verbatim · CDSS document, Jun 19, 2025

Allegation investigated: Facility is not kept in good repair

Licensing Program Analyst (LPA) Valeria Conway conducted a subsequent complaint visit with the purpose of delivering findings for the above listed allegation. LPA met with Executive Director (ED), Aamber Winterstein. Reason for the visit was stated. Entrance interview conducted. During today’s visit a brief physical plant tour of the facility was conducted to ensure health and safety precaution were met. On 04/10/2025, LPA Conway, conducted an initial complaint visit. During that visit, LPA conducted a tour of the physical plant, obtained copy of the resident and staff roster and obtained pertinent information relevant to the investigation. Between 10:30 A.M. and 2:30 P.M. LPA conducted interviews with the ED, Maintenance Director, Director Culinary Services, four (4) residents and two (2) staff members. 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: Continued on LIC 9099-C Substantiated Continued from LIC 9099 On 04/10/2025, LPA Conway, conducted an initial complaint visit. During that visit, LPA conducted a tour of the physical plant, obtained copy of the resident and staff roster and obtained pertinent information relevant to the investigation. Between 10:30 A.M. and 2:30 P.M. LPA conducted interviews with the ED, Maintenance Director, Director Culinary Services, four (4) residents and two (2) staff members. 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: The complaint alleges that the facility provides poor-quality food, limited quantities, and lacks water access to residents. The reporting party expressed concern that facility is experiencing food and water shortage. Interviews with residents revealed mixed feedback regarding food service. Some residents were frustrated by occasional unavailability of specific menu items -such as vanilla ice cream, beets and sourdough bread- despite being listed on the menu, while others shared positive comments, stating that the quality of the food has significantly improved since the facility hired a new Culinary Director. All residents interviewed confirmed that meals have consistently been served as scheduled, with adequate portions and able to get second servings upon request. Additionally, snacks are also accessible at the “Anytime Café” between meals. Interviews with the ED and a walk-through of the facility conducted on 04/22/2025, confirmed that the facility has not experienced shortages of food or water. A large supply of purified water in a storage room, bottled waters and multiple water dispensers were observed. Some water dispensers were low or empty. The LPA discussed this with the ED, who agreed to instruct staff to monitor and refill the dispensers regularly as part of their rounds and ensure regular refills. Two (2) new water dispensers were also installed in the theater room and the upstairs activity room to improve access to residents on all floors. Regarding concerns about food shortages, the Director of Culinary Services reported regular food deliveries twice a week, with occasional substitutions due to vendor shortages, but stated the facility has never run out of food. Record review reflects that the facility receives food deliveries from Sysco every Tuesday and Friday. Continued on LIC 9099-C Continued from LIC 9099-C The LPA reviewed purchase orders dated from 03/11/3035 through 04/08/2025. During the review, it was observed that cases of 8-oz water bottles are consistently being ordered, with regard to food items, it was noted that when the distributor is out of stock on a particular item, it is automatically substituted with similar item to ensure the facility continues to receive necessary supplies without interruption. Inspections showed ample fresh, canned and dry food supplies, including emergency stock. The LPA addressed resident’s concerns about discrepancies between menu descriptions and actual meals with the Ed. The LPA also recommended ordering more of popular items like vanilla ice cream to reduce substitutions and meet resident preferences. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Staff does not ensure food is of good quality and does not has sufficient supply of food in the facility for resident in care” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued. Continued from LIC 9099 The complaint alleges that the facility is not kept in good repair, as the main elevator (large car elevator), has been restricted from use by residents in care since February 2025, per management’s decision. The reporting party is concerned that this ongoing issue poses a significant inconvenience for residents who use wheelchairs or other mobility devices, as they are required to travel across the building to access the only remaining operational, smaller elevator. Interviews with ED revealed that the facility has two (2) elevators, with at least one (1) remaining operational at all times. The main elevator was taken out of service for safety reasons due to a noticeable bump occurring between floors, which posed a fall risk. The ED further explained that a third-party vendor (TK Elevator Corporation) was contracted to perform the necessary repairs, but due to the elevator’s age, a specific part (piston) had to be manufactured and shipped. Although the repair was originally scheduled for early April, it was delayed and rescheduled several times. During today’s visit LPA observed that the main elevator is still out of order, however, per ED elevator is under repair and it will be finalized by 5/23/3025. Interviews conducted with residents and visitors revealed that the current elevator situation has caused considerable inconvenience, particularly for residents living near the main elevator who now have to walk longer distances to access the functional elevator. Several residents expressed frustration, particularly during peak times like meals, when wheelchair and scooters users reduce the available space in the smaller, working elevator, leading to long wait times. Concerns were raised about accessibility and the need for reliable elevator service to ensure safe and reasonable access to common areas. Furthermore, records confirmed that elevator issues were reported to the attention of both the ED and the Maintenance Director during council meetings. On 02/11/2025, it was announced that the main elevator would be taken out of service. On 03/11/2025, it was reported that the repair was both complex and costly, with a hopeful completion date of 04/01/2025. However, on 04/08/2025 the estimate repair date was revised to 05/01/2025. Continued on LIC 9099-C Continued from LIC 9099-C During facility visits conducted on 03/20/2025, 04/10/2025 and on 04/22/2025, the LPA observed “Temporary Out Of Service” signs posted at the front desk and on the double doors leading to the main elevator. Facility records show the repair work order for repair was initiated on 01/22/2025. On 04/17/2025, the LPA requested email correspondence with the vendor, however, the information provided lacked specifics details about the diagnosis or scope of the required repair. On 4/28/2025, the LPA sent a follow-up email requesting additional documentation, including a formal diagnosis, invoice and explanation for delays such as, the expected delivery time frame and any official communication from the supplier verifying that the part was backordered or required manufacturing. As of the date of this report, the LPA has not received the requested documentation. The only response received was an email stating that the repair was first rescheduled for 05/12/2025, then corrected to 05/19/2024. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation of “Facility is not kept in good repair”. Therefore, the above 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.the state’s words, verbatim · CDSS document, May 21, 2025 · control 29-AS-20250404152726

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 4, 2025

87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times...maintenance services and procedures for the safety and well-being of Residents, employees and visitors. This requirement is not met as evidenced by: Based on interviews conducted, observations and records review, the licensee did not comply with the section cited above by having the main elevator out of service for several months which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 21, 2025

Plan of correction: ED agrees to submit a completion documentation to LPA via Email by POC due date.

Allegation investigated: Staff did not keep residents’ personal information confidential Staff yelled at resident.

Licensing Program Analyst (LPA) Valeria Conway conducted a subsequent complaint visit with the purpose of delivering findings for the above listed allegation. LPA met with Executive Director (ED), Aamber Winterstein. Reason for the visit was stated. Entrance interview conducted. During today’s visit a brief physical plant tour of the facility was conducted to ensure health and safety precaution were met. On 12/31/2024 LPA Conway, conducted an initial complaint visit. During that visit, LPA conducted a tour of the physical plant, obtained copy of the resident and staff roster and obtained pertinent information relevant to the investigation. Between 9:51 A.M. and 12:40 P.M. LPA conducted a brief plant tour, interviewed the ED and two (2) staff members. Continued on LIC 9099-C Unsubstantiated Continued from LIC 9099 Additionally, LPA conducted a review of resident's file and obtained copies of pertinent documents relevant to the investigation. Throughout the course of the investigation, LPA reviewed all documents obtained and conducted telephonic interviews with additional credible witnesses and other relevant parties. The Reporting Party (RP) was anonymous therefore, the LPA was unable to obtain additional information regarding the allegations. The following was then determined: On the allegation, “Staff did not keep residents’ personal information confidential” the anonymous complainant’s concern was that staff were discussing confidential information with individuals who neither work at the facility does not have connections to residents in care. Residents interviewed confirmed that they have not overheard any staff members, including those in management, discussing confidential information about other residents in their presence. Additionally, Med Techs interviewed by LPA stated that hey are well-trained and fully understand the importance of maintaining resident’s confidentiality. They consistently refrain from sharing personal information and, when approached by individuals seeking such details, they clearly communicate that they are not authorized to disclose any information and refer inquiries to the resident’s family member directly. The LPA also reviewed staff training records, which were found to be current and comprehensive, including confidential records, ethics, and knowing the rights of residents. Based on the information obtained, the allegation is deemed UNSUBSTANTIATED at this time. LPA recommends that ED continue to discuss policies that ensure residents privacy. On the allegation, “Staff yelled at resident” it was alleged by the anonymous complainant that a facility staff member, described as the Executive Director (ED), was overheard yelling at Resident #1 (R1) and that R1 later complained about the incident to others. In response, an interview with the ED was conducted, during which the ED denied the allegation and affirmed that all residents are treated with dignity and respect. Interviews with multiple residents revealed no concerns regarding staff behavior; residents consistently described staff as kind and denied ever being yelled at by facility staff. Continued on LIC 9099-C Continued from LIC 9099-C R1 was also interviewed and described the facility staff at the facility as “nice” and “helpful” with no indication of experiencing inappropriate behavior. Additionally, staff members interviewed denied ever yelling at residents in care and stated that they have never witnessed other staff members engaging in such conduct. The information obtained during the investigation did not include evidence sufficient to corroborate the above allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 21, 2025 · control 29-AS-20241227114635

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

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 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 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 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.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 29-AS-20250318091807

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 25, 2025

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… 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.the state’s words, verbatim · CDSS document, Apr 22, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.618(c)(2) · Plan of correction due date: May 6, 2025

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… 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.the state’s words, verbatim · CDSS document, Apr 22, 2025

Plan of correction: 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.

Allegation investigated: Due to insufficient staffing, residents are not given medication as prescribed.

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 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 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.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 29-AS-20241227114635

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: May 6, 2025

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… 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.the state’s words, verbatim · CDSS document, Apr 22, 2025

Plan of correction: 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.

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: 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.

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 (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) (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) (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.the state’s words, verbatim · CDSS document, Oct 4, 2024 · control 29-AS-20240426151300

Allegation investigated: Staff handled resident in a rough manner. Staff does not treat resident with respect.

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit to deliver findings on the above noted allegations. LPA met with Administrator/Executive Director (ED) Amber Winterstein and explained the reason for the visit. During today's visit, LPA interviewed the resident services director at 10:40 a.m. and resident 1 (R1) at 11:06 a.m. LPA also reviewed and obtained pertinent documents at 11:46 a.m. R1 receives assistance with showering. On or about 6/5/2024, staff 1 (S1) was assigned to assist R1 with their shower. R1 felt S1 did not bathe them completely and felt S1 required more training. In addition, R1 did not like the way S1 put on their shoes. R1 stated that was the only time S1 assisted with their shower. Unsubstantiated (continued from LIC9099, page 1) R1 complained to the facility administrator at that time and was told by the administrator they would no longer receive showers from S1. R1 likes S1, just not for showering. S1 still assists R1 with other things and R1 has no complaints. R1 likes the current staff assigned to assist with showers. R1 denied ever being handled roughly by staff. Based on information obtained in this interview, the above noted allegations are deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 4, 2024 · control 29-AS-20240610100123

Type of visit: Collateral

Licensing Program Analyst (LPA) Teresa Camara conducted a collateral visit regarding a complaint for another facility (complaint control number 29-AS-20240612094331). LPA met with interim executive director Kawana Anthony, Operations Specialist and explained the reason for the visit. LPA met with Resident 1 (R1) at 3:45 p.m. No deficiencies observed. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Aug 6, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Teresa Camara conducted a required annual visit. LPA met with Executive Director Roman Sierra Tovar and discussed the reason for the visit. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Fire extinguishers were last serviced on 10/11/2023. The maintenance director provided documentation of monthly smoke detector and carbon monoxide detector inspections throughout the facility. Batteries in the detectors are changed once a year. Johnson Controls inspected the fire sprinkler system 3/26/2024 and the fire alarm 5/30/2023. No concerns observed. COMMON SPACES: In the common areas, walls, flooring, and furnishings were checked for cleanliness and good condition. Fireplaces were observed to be adequately screened. LPA observed the required postings in the common hallway and throughout the building. All hallways and egresses were observed to be free of obstructions. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The facility also has a sufficient supply of emergency food and water. All knives and cleaning supplies were observed to be properly stored at the time of the visit. OUTDOOR SPACES: Outdoor spaces in both Assisted Living and Life Guidance were observed. Both contain shaded outdoor areas equipped with furniture for resident use. BEDROOMS: LPA observed eight resident bedrooms in Assisted Living and two resident bedrooms in Life Guidance (Memory Care,) which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Report continued on LIC 809 - C (continued from LIC809) RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. LPA observed sufficient amounts of soap and paper products in each restroom. The hot water temperature was tested in four resident restrooms and all measured above the allowable regulatory range. Temperatures were measured as follows: 134*F, 125.8*F, 122.4*F, and 125.6*F. During the visit the maintenance director stated the facility had just received maintenance on the boiler and the technician may have increased the water temperature. The maintenance director adjusted the hot water temperature during LPA's visit. INFECTION CONTROL/EMERGENCY DISASTER: LPA reviewed with the Executive Director the facility’s infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control and emergency disaster planning are adequate. INTERVIEWS: LPA interviewed ten (10) residents. No citations were issued during today’s visit. An annual continuation visit will be necessary and any deficiencies observed will be cited during that visit. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Jun 14, 2024