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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880599
Report Date: 04/22/2021
Date Signed: 04/22/2021 11:29:08 AM

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:
04/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Celest Williams - AdministratorTIME COMPLETED:
11:15 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 that occurred on 4/11/21. LPA Colvin spoke with Administrator Celest Williams 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 briefly interviewed Administrator Williams regarding the circumstances leading up to R1's admission to the facility and subsequent death. Due to this being the second adult death (under the age of 60) at this facility within 30 days, LPA Colvin requested for Administrator Williams to submit a Resident Roster for the facility for January 2021 - Present. An Informal Meeting has been scheduled for this facility for Tuesday, 4/27/21 at 3:00pm. LPA Colvin requested that all documents be submitted by then, along with Administrator's Clearance ID, as there has been a recent change in Administrator which is still processing.

A copy of this report was discussed and provided to Administrator Celest Williams 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: 04/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021
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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