<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880599
Report Date: 05/24/2023
Date Signed: 05/24/2023 09:39:45 AM

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
04/18/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230418132327
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: 54DATE:
05/24/2023
UNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Rebecca ParraTIME COMPLETED:
09:37 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not address a change in resident's health condition
Staff don't ensure that resident attends scheduled doctor appointments
Staff mismanaged resident medications
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator Rebecca Parra and explained the purpose of the visit. The investigation consisted of interviews and a review of records.

First allegation: staff did not address a change in residents’ health condition.

Regarding the first allegation, staff did not address a change in residents’ health condition. LPA Guerrero reviewed Residents #1 (R1) medical records and observed that facility does not have an updated or/current (2023), physicians report which indicates Residents #1 change in health condition or R1 diagnosis. Based on the facilities admission agreement it is stated that a physician’s report shall be updated minimum, yearly, whenever significant changes in residents, health may occur.

Second Allegation: Staff don't ensure that resident attends scheduled doctor appointments.

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: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
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 5
Control Number 56-AS-20230418132327
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: 05/24/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the second allegation, staff don’t ensure that resident attends scheduled doctor
appointments. LPA Guerrero reviewed Resident #1 (R1) records and observed that no current medical appointments have been scheduled for resident R1. On 4/18/23 Resident #1 attended a medical appointment, Care Coordinator stated Resident #1 was alone. It is stated that R1 has missed several appointments and due to R1 forgetfulness it is not safe for R1 to attend medical appointments alone. Based Resident #1 (R1) admissions agreement (mental condition), k) resident is able to leave facility unassisted, indicates “No”.

Third allegation: Staff mismanaged resident medications


Regarding the third allegation, staff mismanaged resident medications. Based on documentation LPA observed that Resident #1 was seen by emergency department (ED) for heart failure R1 was given temporary medication which medication is not listed on Resident #1 medication check list. In addition, Resident #1 was diagnosed with diabetes which recent diagnosis is not listed in physicians report, and no known diabetes medication is listed in Resident’s #1 medication check list. Based on the evidence gathered during the investigation, the above allegations are SUBSTANTIATED.

Substantiated; A finding that the complaint is Substantiated means that the residents’ is valid because the preponderance of the evidence standard has been met. Title 22 regulations 87465 incidental medical and dental care from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.

An exit interview was conducted where this report was discussed and provided to Facility Administrator Rebecca Parra.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
04/18/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230418132327

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: 54DATE:
05/24/2023
UNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Rebecca ParraTIME COMPLETED:
09:37 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not safeguard resident's personal property
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator Rebecca Parra and explained the purpose of the visit. The investigation consisted of interviews and a review of records.

First allegation: Staff did not safeguard resident's personal property.

Regarding the first allegation, staff did not safeguard residents’ personal property. Based on interviews and record review staff deny ever taking or misplacing Resident #1 belongings. Facility does not have an inventory check list for Resident # 1 however, Staff #1-3 stated that they have not witnessed staff remove or take Resident #1 (R1) belongings without Resident # 1 consent. Due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20230418132327
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: 05/24/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report was discussed and provided to Facility Administrator Rebecca Parra.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20230418132327
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: 05/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2023
Section Cited
CCR
87465(1)(2)
1
2
3
4
5
6
7
Incidental medical and dental care (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator will read over the entire regulation 87465 and provide training for staff who provides medical assistance and medical changes for residents. Administrator will provide both acknowledgement and traning sign in sheet that provides date and time of when traning took place. Administrator will email documentation to LPA on POC due date 6/30/23
8
9
10
11
12
13
14
Based on obervation, interviews and record review, the licnesee did not ensure incidental medical and dental care was obatained for residents, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
Type B
06/30/2023
Section Cited
CCR
87465(e)
1
2
3
4
5
6
7
Incidental medical and dental care For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication.
1
2
3
4
5
6
7
staff who manages and dispense medication to residents. Administrator will provide both acknowledgement and traning sign in sheet that provides date and time of when traning took place. Administrator will email documentation to LPA on POC due date 6/30/23
8
9
10
11
12
13
14
Based on obervation, interviews and record review, the licnesee did not ensure incidental medical and dental care was obatained for residents, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
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: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5