Inspection Report Summary
Most inspections found no deficiencies, with several complaint investigations unsubstantiated, reflecting generally good compliance over time. The most recent report from October 27, 2025, cited a serious deficiency for allowing a new administrator to work before fingerprint clearance, resulting in a $500 fine and an immediate health and safety risk. Earlier reports noted staffing shortages that affected medication administration and safety concerns such as a broken elevator and malfunctioning pagers in the memory care unit, but these issues were isolated and addressed. The facility showed improvement in some areas, with no deficiencies in several annual inspections and many complaints found unsubstantiated. While some challenges remain, particularly around staffing and administrative compliance, recent findings suggest the facility is managing these concerns without widespread or repeated problems.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 112
Capacity: 140
Deficiencies: 1
Oct 27, 2025
Visit Reason
The inspection was an unannounced Case Management Deficiency visit conducted in conjunction with an initial 10-day complaint visit to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.
Findings
The facility was cited for a Type A deficiency related to failure to ensure the new Administrator had fingerprint association transferred to the facility prior to working, posing an immediate health and safety risk to residents. An immediate civil penalty of $500 was assessed for this violation.
Complaint Details
The visit was triggered by an initial 10-day complaint visit (CC #29-AS-20251020160401). The deficiency cited was not related to the complaint but was observed during the complaint investigation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the new Administrator had fingerprint association transferred to the facility prior to working, posing an immediate health and safety risk to residents. | Type A |
Report Facts
Civil penalty amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Remon Pagels | Interim Executive Director | Met with Licensing Program Analyst during the inspection |
| Valeria Conway | Licensing Program Analyst | Conducted the unannounced Case Management Deficiency visit |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 112
Capacity: 140
Deficiencies: 3
Jun 19, 2025
Visit Reason
The visit was an unannounced required annual inspection to ensure compliance with Title 22 regulations and assess health and safety conditions at the facility.
Findings
The facility was generally found to be in compliance with regulations, including kitchen, dining, and outdoor areas. However, deficiencies were noted related to malfunctioning pagers in the memory care unit posing a potential safety risk and discrepancies in medication start dates. Hot water temperature violations were also corrected during the visit. Emergency plans and records were reviewed and found complete.
Severity Breakdown
Type B: 1
Technical advisory: 1
Technical violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Malfunctioning pagers in the memory care unit posed a potential health, safety, or personal rights risk to persons in care. | Type B |
| Two out of five centrally stored medication start dates did not match the medication and destruction record. | Technical advisory |
| Hot water temperature in four out of eleven resident rooms was above the required range. | Technical violation |
Report Facts
Census: 112
Total Capacity: 140
Resident rooms inspected: 11
Resident files reviewed: 10
Personnel files reviewed: 10
Residents interviewed: 3
Staff interviewed: 4
Medications reviewed: 5
Water fountains observed: 3
Fire sprinkler inspection date: Feb 25, 2022
Fire extinguisher last serviced: Aug 30, 2024
Last disaster drill date: May 21, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amber Winterstein | Executive Director | Met with Licensing Program Analysts during inspection and involved in discussion of findings |
| Valeria Conway | Licensing Program Analyst | Conducted inspection and signed report |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 140
Deficiencies: 1
May 21, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2025-04-04 regarding facility maintenance and food quality/supply concerns.
Findings
The complaint that the facility is not kept in good repair was substantiated due to the main elevator being out of service for several months, posing a health and safety risk. The complaint regarding poor food quality and insufficient supply was unsubstantiated, with evidence showing adequate food and water supplies and regular deliveries.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility is not kept in good repair due to the main elevator being out of service since February 2025, causing inconvenience and safety concerns for residents. The allegation regarding poor food quality and insufficient supply was unsubstantiated based on interviews, observations, and document reviews.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility shall be clean, safe, sanitary and in good repair at all times; the main elevator was out of service for several months posing a potential health and safety risk to residents. | Type B |
Report Facts
Facility capacity: 140
Resident census: 112
Plan of Correction due date: 2025
Food delivery frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Valeria Conway | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Amber Winterstein | Executive Director | Met with Licensing Program Analyst during investigation and referenced in findings |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 140
Deficiencies: 0
May 21, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 12/27/2024 regarding staff confidentiality breaches and staff yelling at a resident.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Residents and staff interviews, document reviews, and training records supported that confidentiality was maintained and staff treated residents with dignity and respect. The allegations were deemed unsubstantiated.
Complaint Details
The complaint involved two allegations: 1) Staff did not keep residents’ personal information confidential, and 2) Staff yelled at a resident. Both allegations were investigated through interviews, document reviews, and observations. The Reporting Party was anonymous. The investigation concluded both allegations were unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 140
Census: 112
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Valeria Conway | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation |
| Aamber Winterstein | Executive Director | Interviewed during investigation and named in allegation of yelling at resident |
| Roman Sierra Tovar | Administrator | Facility administrator listed in report header |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 140
Deficiencies: 1
Apr 22, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation received on 2024-12-27 regarding insufficient staffing causing residents to not receive medication as prescribed.
Findings
The investigation found substantiated evidence that staffing shortages caused medication administration issues, including discrepancies in medication records and delays in medication delivery. Staffing gaps were observed, with only one caregiver and one Med-Tech on duty during shifts, and multiple employees working double shifts or on days off. The Executive Director acknowledged staffing challenges but maintained medication administration as a priority.
Complaint Details
The complaint alleged that due to insufficient staffing, residents were not given medication as prescribed. The allegation was substantiated based on interviews, document reviews, medication audits, and observed staffing shortages. Medication discrepancies were found in 8 out of 10 residents' records. The Executive Director acknowledged staffing challenges but asserted adequate staffing levels. Residents reported delays and missed medication doses.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel were not sufficient in numbers to perform essential duties for residents, violating CCR 87411(a). | Type B |
Report Facts
Medication audit discrepancies: 8
Medication audits conducted: 3
Plan of Correction due date: May 6, 2025
Census: 112
Total capacity: 140
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Valeria Conway | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation. |
| Roman Sierra Tovar | Administrator | Facility Administrator involved in the investigation and informed of deficiencies. |
| Amber Winterstein | Executive Director | Met with Licensing Program Analyst during investigation and acknowledged staffing challenges. |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 140
Deficiencies: 2
Apr 22, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-03-18 regarding medication refill delays, improper medication administration, and insufficient staffing at the facility.
Findings
The investigation substantiated that staff failed to timely refill residents' medications, resulting in missed doses and medication discrepancies. Additionally, staffing shortages were confirmed, causing delays in care and medication administration, with staff reporting being overworked and stressed.
Complaint Details
The complaint investigation was substantiated. Allegations included staff not refilling residents' medications timely, staff not administering medications as prescribed, and insufficient staffing. Evidence showed medication lapses for Resident #1 and discrepancies in medication records for 8 of 10 residents reviewed. Staffing shortages were confirmed with staff reporting overwork and extended wait times for residents.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to assist residents with self-administered medications as needed, resulting in missed medication doses and potential health risks. | Type A |
| Insufficient staffing levels to ensure health, safety, comfort, and supervision of residents, posing potential health and safety risks. | Type B |
Report Facts
Medication audits: 3
Residents reviewed in medication audit: 10
Deficiency count: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amber Winterstein | Executive Director | Met during investigation; named in findings related to medication and staffing deficiencies. |
| Valeria Conway | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 140
Deficiencies: 0
Oct 4, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of neglect and lack of care and supervision involving Resident #1 who sustained a fracture and was allegedly left on the floor for an extended period.
Findings
The investigation reviewed video footage, medical records, and conducted interviews, concluding that the facility staff responded timely to Resident #1's fall and did not neglect care or fail to follow the care plan. All allegations were deemed unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint alleged neglect/lack of care and supervision resulting in Resident #1 sustaining a fracture and being left on the floor for an extended time, staff not following the care plan, and staff going through resident's personal belongings without consent. The investigation found no sufficient evidence to substantiate these allegations; the complaint was unsubstantiated.
Report Facts
Facility capacity: 140
Resident census: 119
Paramedics arrival time: 15
Time between last check and fall: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation visit and delivered final findings |
| Amber Winterstein | Administrator/Executive Director | Met with Licensing Program Analyst during investigation |
| Jasmin Mendez | Investigator | Assigned to the complaint investigation |
| Kelly Dulek | Licensing Program Analyst | Conducted initial 10-day complaint visit and facility tour |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 140
Deficiencies: 0
Oct 4, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-06-10 regarding staff handling residents roughly and not treating residents with respect.
Findings
The investigation included interviews with the resident services director and a resident. The resident reported dissatisfaction with staff assistance during showering but denied rough handling. The allegations were deemed unsubstantiated, and no deficiencies were cited.
Complaint Details
The complaint involved allegations that staff handled a resident roughly and did not treat the resident with respect. After investigation, including interviews and document review, the allegations were found unsubstantiated.
Report Facts
Capacity: 140
Census: 119
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation visit |
| Amber Winterstein | Administrator/Executive Director | Met with Licensing Program Analyst during the investigation |
| Desaree Perera | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 140
Deficiencies: 0
Aug 6, 2024
Visit Reason
Licensing Program Analyst Teresa Camara conducted a collateral visit regarding a complaint for another facility (complaint control number 29-AS-20240612094331).
Findings
No deficiencies were observed during the visit. An exit interview was conducted and the report was issued.
Complaint Details
The visit was related to a complaint investigation for another facility, identified by complaint control number 29-AS-20240612094331. No deficiencies were found at this facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the collateral visit and inspection. |
| Kawana Anthony | Interim Executive Director | Met with Licensing Program Analyst during the visit. |
Inspection Report
Annual Inspection
Census: 108
Capacity: 140
Deficiencies: 0
Jun 14, 2024
Visit Reason
Licensing Program Analyst Teresa Camara conducted a required annual visit to ensure the facility's compliance with Title 22 Regulations and to assess health and safety conditions.
Findings
The facility was found to be in compliance with no health or safety hazards observed. Fire safety equipment was properly maintained, common areas and resident rooms were clean and well-maintained, and infection control and emergency disaster plans were adequate. No citations were issued during this visit.
Report Facts
Hot water temperatures: 134
Hot water temperatures: 125.8
Hot water temperatures: 122.4
Hot water temperatures: 125.6
Number of residents interviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the annual inspection and interviews |
| Roman Sierra Tovar | Executive Director | Met with Licensing Program Analyst to discuss the reason for the visit |
| Desaree Perera | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Annual Inspection
Census: 125
Capacity: 140
Deficiencies: 1
Jun 14, 2023
Visit Reason
The inspection was an unannounced required annual visit to evaluate the facility's compliance with Title 22 regulations and ensure health and safety standards were met.
Findings
The facility was found to be in good condition with no health or safety hazards observed. All common areas, kitchen, outdoor spaces, bedrooms, restrooms, and records were compliant with regulations. Medications for three residents were reviewed with one minor labeling issue noted for over-the-counter medications. No citations were issued.
Deficiencies (1)
| Description |
|---|
| One resident's over-the-counter medications were centrally stored but not labeled in compliance with regulation. |
Report Facts
Resident bedrooms observed in Assisted Living: 8
Resident bedrooms observed in Life Guidance: 2
Total resident bedrooms: 123
Assisted living resident rooms: 107
Life Guidance resident rooms: 16
Resident restrooms observed: 10
Staff files reviewed: 5
Resident files reviewed: 5
Staff interviewed: 3
Residents interviewed: 3
Residents' medications reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robloe Babasanta | Executive Director | Met with Licensing Program Analyst during inspection and discussed visit reason |
| Kelly Dulek | Licensing Program Analyst | Conducted the annual inspection visit |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 115
Capacity: 140
Deficiencies: 3
Jun 16, 2022
Visit Reason
An unannounced Required - 1 Year inspection was conducted to evaluate the facility's compliance with infection control practices and other regulatory requirements.
Findings
The inspection found several infection control and safety issues, including accessible hazardous items such as medications, scissors, tools, and alcohol to residents, posing immediate health and safety risks. The facility had adequate infection control supplies and safety equipment but failed to secure certain items properly.
Severity Breakdown
Type A: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| S2's medication and S1's contact lens drops were accessible to residents, posing an immediate health risk. | Type A |
| Tools and scissors were accessible to residents, posing an immediate health and safety risk. | Type A |
| Alcohol and toxic substances were accessible to residents, posing an immediate health risk. | Type A |
Report Facts
Census: 115
Total Capacity: 140
POC Due Date: Jun 16, 2022
POC Due Date: Jun 17, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robloe Babasanta | Administrator | Met with Licensing Program Analyst during inspection and named in findings related to securing hazardous items |
| Joann Rosales | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 140
Deficiencies: 4
Apr 1, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted to deliver findings related to multiple allegations concerning resident care and facility conditions at Atria Las Posas.
Findings
The investigation substantiated allegations that a resident's room was not properly maintained, the resident was not provided comfortable accommodations, was not properly groomed, laundry needs were not met, and the resident was charged for services not received. One allegation regarding unmet dental needs was unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations related to poor room maintenance, uncomfortable accommodations, inadequate grooming, unmet laundry needs, and charging for services not received. The allegation regarding unmet dental needs was unsubstantiated.
Severity Breakdown
Type B: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to maintain resident's room clean resulting in smelling of urine and/or feces posing a potential health risk. | Type B |
| Failed to ensure the facility removed trash from the resident's room posing a potential health risk. | Type B |
| Failed to meet basic care needs such as grooming posing a potential health and safety risk. | Type B |
| Failed to ensure safe and healthful living accommodations and services including laundry needs posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 140
Census: 118
Deficiency count: 4
Plan of Correction Due Date: Apr 30, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Martha Guzman-Chavez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Robloe Babasanta | Executive Director | Facility representative interviewed during investigation and named in findings |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 140
Deficiencies: 0
Aug 3, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that a resident was not having their needs met, the facility was failing to adhere to a special diet for the resident, and that the resident was placed at the facility against their will.
Findings
The investigation found that the resident had a private caregiver for doctor appointments and grocery shopping, the facility made efforts to accommodate the resident's special diet despite some disagreements, and the resident was not placed against their will but moved in with family support. All allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included unmet resident needs, failure to adhere to a special diet, and involuntary placement. Interviews and record reviews showed the resident had a private caregiver, dietary accommodations were made, and the resident moved voluntarily with family assistance.
Report Facts
Facility capacity: 140
Resident census: 125
Complaint received date: Dec 5, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Martha C Berard | Administrator | Facility administrator interviewed during the investigation |
Inspection Report
Annual Inspection
Capacity: 140
Deficiencies: 0
Jun 8, 2021
Visit Reason
The visit was a required unannounced annual inspection with a specific emphasis on infection control practices and procedures.
Findings
The facility was found to be in compliance with health and safety regulations, including clean and appropriately furnished resident bedrooms, sanitary restrooms, well-maintained common areas, and adequate infection control practices. No citations were issued during the visit.
Report Facts
Total bedrooms: 123
Number of entry points: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robloe Babasanta | Administrator | Met with Licensing Program Analysts during the inspection and discussed the reason for the visit |
| Angel Ascencio | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kelly Dulek | Licensing Program Analyst | Conducted the inspection |
| Kristin Heffernan | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 140
Deficiencies: 0
Feb 26, 2021
Visit Reason
The inspection was initiated as a Case Management - Incident inspection due to a self-reported incident report involving two residents, occurring around February 23, 2021.
Findings
The Licensing Program Analyst conducted a telephonic complaint investigation due to COVID-19 mitigation measures and did not observe any health and safety concerns during a virtual tour of the facility. Further investigation was assigned to an investigator.
Complaint Details
The visit was complaint-related based on a self-reported Unusual Incident/Injury Report (LIC 624) involving Resident #1 and Resident #2. The investigation was ongoing and assigned to an Investigations Branch Investigator.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deedee Higgins | Life Guidance Director | Spoke with the Licensing Program Analyst during the telephonic complaint investigation and provided a virtual tour of the facility. |
| Robloe Babasanta | Administrator | Unavailable during the inspection; mentioned as the facility administrator. |
| Kasandra Lopez | Licensing Program Analyst | Initiated and conducted the Case Management - Incident inspection. |
| Laura Garcia | Investigations Branch Investigator | Assigned to the ongoing investigation. |
| Kelly Burley | Licensing Program Manager | Named in the report header. |
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