Atria las Posas.

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) M ed-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 hour s. 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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

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. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC 9099-C Third page was intentionally left blank. A hard copy of this page was emailed for signature.

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 27 th and Saturday June 28 th , 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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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 co ntinuity 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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC 9099-C To further investigate these concern s, 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 foll owing 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.