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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880599
Report Date: 04/26/2023
Date Signed: 04/26/2023 10:49:58 AM


Document Has Been Signed on 04/26/2023 10:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:LOTUS VILLA AND MEMORY CAREFACILITY NUMBER:
361880599
ADMINISTRATOR:REBECCA PARRAFACILITY TYPE:
740
ADDRESS:9448 CITRUS AVETELEPHONE:
(909) 355-6887
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:99CENSUS: 49DATE:
04/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Stacy LopezTIME COMPLETED:
10:48 AM
NARRATIVE
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Licensing Program Analysts (LPA) Paola Guerrero conducted an unannounced visit to the facility on 04/26/23 at 9:14 AM for the purpose of a Health & Safety check. LPA Guerrero identified herself to Facility Manager Stacy Lopez and discussed the purpose of the visit. Residents in care were present during visit. No imminent health and/or safety concerns observed at the time of visit. LPA Guerrero inspected the outside perimeter of the facility and observed no health and/or safety hazards. LPA Guerrero observed sufficient staff present at the facility to provide care. LPA Guerrero inspected facility food supplies and observed three (3) day supply of perishable and seven days (7) supply of non-perishable food. The needs of the residents in care appear to be met during this inspection.

An exit interview was conducted where this report (LIC809) was discussed and provided to Facility Manager Stacy Lopez
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023
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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