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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880599
Report Date: 04/07/2023
Date Signed: 04/07/2023 12:10:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/29/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230329095049
FACILITY NAME:LOTUS VILLA AND MEMORY CAREFACILITY NUMBER:
361880599
ADMINISTRATOR:DEBORAH P HIGGINSFACILITY TYPE:
740
ADDRESS:9448 CITRUS AVETELEPHONE:
(909) 355-6887
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:99CENSUS: 45DATE:
04/07/2023
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Rebecca ParraTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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9
Staff are not ensuring resident is receiving dental care.
Staff are not providing assistance with resident oral hygiene.
Staff are not providing resident assistance with grooming care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to initiate and deliver the findings for the above complaint allegations. LPA met with Facility Administrator Rebecca Parra who was informed of the purpose of my visit and the allegations listed above. The investigation consists of direct observations, records review, and interviews with staff and residents regarding the above allegations.

First Allegation: Staff are not ensuring resident is receiving dental care.

Regarding first allegation: Staff are not ensuring resident is receiving dental care. Licensing Program Analyst (LPA) Paola Guerrero conducted in person interviews with Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), who all stated that they have not taken notice to Resident #1 (R1) oral hygiene.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 56-AS-20230329095049
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 361880599
VISIT DATE: 04/07/2023
NARRATIVE
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LPA conducted a record review of the facilities admission agreement which states in the facility service agreement (14); that the facility will provide assistance in meeting necessary medical and dental needs by arranging medical and dental appointments and contacting emergency services. LPA observed that no dental arrangements/or appointments were on file for Resident #1 (R1).

Second Allegation: Staff are not providing assistance with resident oral hygiene.

Regarding second allegation Staff are not providing assistance with resident oral hygiene. Licensing Program Analyst (LPA) Paola Guerrero conducted in person interviews with Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), who all stated that assistance with oral hygiene is provided to Resident #1 (R1). LPA observed Resident #1 (R1) gums to be white, red, and inflamed. LPA received photos which demonstrates Resident #1 (R1) dental sate. LPA asked Staff #1-3 if notice have not been taken regarding Resident #1 (1) dental condition Staff #1-3 stated that they have not taken notice of Resident #1 (R1) dental condition. LPA conducted a record review of the facilities admission agreement which states in the facility service agreement under grooming; that the facility will provide assistance in meeting necessary medical and dental needs (11)-(14).

Third Allegation: Staff are not providing resident assistance with grooming care.

Regarding third allegation Staff are not providing resident assistance with grooming care. Licensing Program Analyst (LPA) Paola Guerrero conducted in person interviews with Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), who all stated that grooming conditions (cutting of nails), has been a concern that has been brought up in the past. LPA interviewed Resident #1 (R1), Resident #2 (R2), and Resident #3 (R3). All who stated that they have not been seen by a pediatrist. Resident #2 stated that it’s been a while since pediatrist services have been provided and appointments have been getting canceled. Resident #3 (3) stated that facility does not have a podiatrist and it’s been a little over a year since podiatry services have been provided. LPA observed Resident #1 (R1), Resident #2 (R2), toenails to be overgrown and long. LPA observed Resident #1 (R1) toenails to be overgrown and curved in-wards. LPA conducted a record review of the facilities admission agreement which states in the facility service agreement under grooming; that the facility will provide assistance in meeting necessary medical and dental needs (11).

Based on the evidence gathered during investigation, the above allegations are Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations Incidental Medical and Dental Care 87465 (a)(1)(2), along with Basic Services 87464(c)(4) from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.


An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Administrator Rebecca Parra at the end of the visit.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20230329095049
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 361880599
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited
CCR
87465(a)(1)(2)
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Incidental Medical and Dental Care (a) plan for incidental medical and dental care shall be developed by each facility... (1) The licensee shall arrange, or assist in arranging, for medical and dental care.. (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met by evidence by:
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Administrator acknowledges the importance in providing good care services to residents while in care. Administrator stated appointments will be scheduled accordingly. Administrator stated that documentation will provided to CCL on 4/28/2023 Via Email.
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Based on observations, interviews and record review, the licensee did not ensure to maintain Incidental Medical and Dental Care at the facility, which poses a possible Health, Safety, or Personal Rights to persons in care
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Administrator acknowledges the importance in providing good care services to residents while in care. Administrator stated that appointment for a podiatrist has been scheduled. Administrator stated that documentation will provided demonstrating service plan along with future podiatrist visits to CCL on 4/28/2023 Via Email.
Type B
04/28/2023
Section Cited
CCR
87464(c)(4)
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Basic Services (c) The admission agreement shall specify which of the Basic services are desired and/or needed by, and will be provided for, each resident...(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal.. This requirement is not met by evidence by:
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Based on observations, interviews and record review, the licensee did not ensure to maintain Basic Services at the facility, which poses a possible Health, Safety, or Personal Rights to persons in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3