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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880599
Report Date: 04/06/2021
Date Signed: 04/14/2021 04:18:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:LOTUS VILLA AND MEMORY CAREFACILITY NUMBER:
361880599
ADMINISTRATOR:JEFFERY (JEFF) A. GOLLIHARFACILITY TYPE:
740
ADDRESS:9448 CITRUS AVETELEPHONE:
(909) 355-6887
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:99CENSUS: 25DATE:
04/06/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jeff Gollihar - AdministratorTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Crystal Colvin contacted the facility via telephone due to COVID-19 in order to conduct a Case Management tele-visit to collect information regarding an adult death. LPA Colvin spoke with Administrator Jeff Gollihar who was informed of the purpose of the call.

LPA Colvin requested the following documents from resident #1's (R1) file for review:

• ID/Emergency Contact Information
• Admissions Agreement
• Physician’s Report
• Doctor’s Notes/Orders
• Pre-Admission Appraisal
• Needs and Services Plan
• Staff Notes
• Medication Records
• Hospital Discharge Paperwork
• Hospice Care Plan

LPA Colvin additionally breifly interviewed Administrator Gollihar regarding the circumstances leading up to R1's admission to the facility and subsequent death. Administrator Jeff Gollihar stated he was unsure if a coroner's report was requested, and stated that he would update LPA Colvin and provide a copy along with the death certificate when available.

A copy of this report was discussed and provided to Administrator Jeff Gollihar via email. Facility representative signature obtained.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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