ATRIA LAS POSAS

Official classification

Type B

Official code

87312

Regulation authority

CCR

What the official deficiency says

87312 Motor Vehicles Used in Transporting Residents Only drivers licensed for the type of vehicle operated shall be permitted to transport residents. The rated seating capacity of the vehicles shall not be exceeded. Any vehicle used by the facility to transport residents shall be maintained in a safe operating condition. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above as the facilitys' vehicles used to transport residents were not covered by automobile liability insurance (expired on 06/01/2026) while being operated on public roads which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/12/2026 Plan of Correction ED agreed to provide current liability insurance for the Ford Flex and facility's bus.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above as their business liability insurance had expired on 06/01/2026 which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/12/2026 Plan of Correction ED agreed to provide current liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. prior to POC due date.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above as some of the medications on hand compared to the Centrally Stored Medication and Destruction Record (LIC 622) were not listed on the LIC 622 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/23/2026 Plan of Correction ED agreed to provide an in-service training to all MedTechs regarding medication documentation requirements, ensure that all current LIC 622 are accurately complete and implement disciplinary action, if applicable, for staff found to be noncompliant with facility policies and procedures. Proof of in-service training and other documentation will be provided to LPA prior to POC due date.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Mar 12, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Feb 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

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

Deadline recorded: Oct 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Sep 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(i)(1)(B)

Regulation authority

CCR

What the official deficiency says

(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by having mulfuntioning pagers in the memory care unit in use which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/19/2025 Plan of Correction During today's visit, pagers were replaced. POC Cleared.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

ED agrees to submit a completion documentation to LPA via Email by POC due date.

Deadline recorded: Jun 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Apr 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.618(c)(2)

Regulation authority

HSC

What the official deficiency says

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.

Official 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.

Deadline recorded: May 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: May 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations and record review, the licensee did not comply with the section cited above as S2's medication and S1's contact lens drops were accessible to residents which poses an immediate health risk to persons in care.

Official plan of correction

POC Due Date: 06/16/2022 Plan of Correction Administrator locked S1 and S2's doors during facility visit. Administrator stated that they will provide documentation of staff inservice regarding regulation 87309(a) to CCL by 6/24/22.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations and record review, the licensee did not comply with the section cited above tools and scissors were accessible to residents which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/17/2022 Plan of Correction Staff placed maintenance cart in an inaccessible location during facility visit, Administrator locked S1 and S2's offices during facility visit. Administrator stated that they will provide documentation of staff inservice regarding regulation 87705(f)(1) to CCL by 6/24/22.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations and record review, the licensee did not comply with the section cited above as alcohol and toxic substances were accessible to residents which poses an immediate health risk to persons in care.

Official plan of correction

POC Due Date: 06/17/2022 Plan of Correction Staff placed toxic items in an inaccessible location during facility visit. Administrator stated that they will have staff remove alcohol from Happy Hour Cafe and will submit documentation to CCL by 6/17/22. Administrator stated that they will provide documentation of staff inservice regarding regulation 87705(f)(2) to CCL by 6/24/22.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(2) Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: to be accorded safe, healthful and comfortable accommodations… This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as they failed to maintain R1’s room clean resulting in smelling of urine and/or feces which poses a potential health risk to residents in care.

Official plan of correction

The ED will conduct an in-house training with all staff pertaining to Title 22 Regulation 87468.1 - Personal Rights of Residents in All Facilities and submit proof. Submit to CCL by 4/30/22.

Deadline recorded: Apr 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)(f)(1)

Regulation authority

CCR

What the official deficiency says

87303(a)(f)(1) – Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times… Solid waste shall be stored, located and disposed of in a manner that will not permit the transmission of a communicable disease or of odors… This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as they failed to ensure the facility removed trash from the R1’s room which poses a potential health risk to residents in care.

Official plan of correction

The ED will submit plan on how you will ensure resident rooms are maintained in a clean and sanitary condition and submit the cleaning log for the month of April 2022. Submit to CCL by 4/30/22.

Deadline recorded: Apr 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464(f)(1) Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as the facility did not ensure that R1’s basic care needs such as grooming were met, which poses a potential health and safety risk to residents in care.

Official plan of correction

The ED has agreed to submit a Statement of Understanding explaining the steps the facility will follow to avoid similar issues from happening again regarding meeting basic care needs of the residents. Submit to CCL by 4/30/2022.

Deadline recorded: Apr 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(2)

Regulation authority

CCR

What the official deficiency says

87464(f)(2) - Basic Services. Basic services shall at a minimum include… Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above, as they failed to ensure the residents laundry needs were met which poses a potential health and safety risk to residents in care.

Official plan of correction

The ED will conduct an in-house training with housekeeping that will include basic services training. Submit to CCL by 4/30/22.

Deadline recorded: Apr 30, 2022. A deadline is not proof that correction was completed.