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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880599
Report Date: 07/05/2023
Date Signed: 07/05/2023 10:54:32 AM


Document Has Been Signed on 07/05/2023 10:54 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, 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: 65DATE:
07/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator Rebecca ParraTIME COMPLETED:
10:55 AM
NARRATIVE
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On 07/05/2023 at 09:15 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility for a Case Management Deficiency visit. LPA Brown identified herself and discussed the purpose of the visit with Administrator Rebecca Parra.

During the facility on 07/05/2023, LPA Brown requested a copy of LIC500 Personnel Report from Administrator Rebecca Parra and per LPA Brown’s review, LPA Brown observed Staff # 14 (S14) and Staff # 17 (S17) with criminal background clearance, but the facility failed to transfer S14 and S17 to the facility. Administrator Rebecca Parra confirmed with LPA Brown that S14 had been employed since 01/01/2023 and S17 had been employed since 04/21/2023. LPA Brown explained to Administrator Parra that deficiency will be issued as this pose potential health, safety and personal rights risks to residents in care.



A civil penalty of $500.00 was assessed per individual for S14 and S17 working at the facility with criminal background clearance but the facility failed to transfer S14's and S17’s criminal background clearance to the facility and S14 and S17 to be associated to the facility. The civil penalty will continue to be assessed of $100.00 per day until corrected during the visit.

An exit interview was conducted where this report, LIC809, along with LIC809D, LIC421BG and Appeal Rights were discussed and provided to Administrator Rebecca Parra.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/05/2023 10:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: LOTUS VILLA AND MEMORY CARE
FACILITY NUMBER: 361880599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2023
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working...(2) Request a transfer of a criminal record clearance... This requirement is not met as evidenced by:
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Licensee stated to train all staff on CCR 87355(e)(2) and submit proof of Training Log to LPA Brown by POC due date.
Licensee stated to associate S14 and S17 by POC due date and submit proof to LPA Brown by POC due date. S14 and S17 associated to the facility during the visit.
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Based on observation, interview and records review, the Licensee did not comply with the section cited above by failing to trasfer the criminal backround clearance of S14 and S17 to the facility before allowing them to work at the facility which pose potential health, safety and personal rights risks to residents 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: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
LIC809 (FAS) - (06/04)
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