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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880599
Report Date: 08/12/2023
Date Signed: 08/12/2023 10:19:55 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
05/16/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230516122855
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: 66DATE:
08/12/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Syrina CanezTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff are not properly keeping records of medications being distributed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Wellness Director Syrina Canez and explained the purpose of the visit. The investigation consisted of interviews and review of records.

Allegation: Staff are not properly keeping records of medications being distributed.

Regarding the first allegation, Staff are not properly keeping records of medications being distributed. LPA conducted a medication inspection in facilities med room LPA observed medication pill card not matching with record/disposition form. LPA observed record form indicating 25 out of 30 pills were remaining, while pill card indicated 23 out of 30 pills were remaining. LPA observed that medication (narcotic), card did not match with record/disposition form. Based on the evidence gathered during the investigation, the above allegation is SUBSTANTIATED.
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: 08/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2023
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-20230516122855
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: 08/12/2023
NARRATIVE
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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(3) 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 Wellness Director Syrina Canez

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

DATE: 08/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20230516122855
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: 08/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2023
Section Cited
CCR
87465(3)
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Incidental Medical and Dental Care...
(3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record..
This requirement is not met as evidence by:
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Administrator/and Wellness Director will read the entire Incidental Medical and Dental Care regulation, will train staff utilizing a third party pharmacy and will provide proof of training on record keeping of: (Narcotics/PRN medication) for all staff handling medication. trainings/certificates will be sent via email to responsible LPA by 9/1/2023.
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Based on observation, interviews and record review, the licensee did not ensure Incidental Medical and Dental Care was obtained, which poses an immediate Health, Safety, or Personal Rights risk 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: 08/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 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
05/16/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230516122855

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: 66DATE:
08/12/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Syrina CanezTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
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Staff dispensed incorrect medications
Staff do not ensure the disposal of expired, discontinued medications
Facility does not ensure staff are trained on medication assistance
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Wellness Director Syrina Canez and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, Staff dispensed incorrect medications. LPA conducted a medication inspection in facilities med room LPA inspected facilities MAR records along with medication cards LPA observed both records matching according to the medication that is being dispensed.

Second allegation, Staff do not ensure the disposal of expired, discontinued medications. LPA conducted an inspection on disposal of medications LPA observed and collected records pertaining to the company (ATI-Medical Waste Management), company who disposes medication for facility. LPA observed that facility had a disposal scheduled pick up set up for May 22,2023.
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: 08/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20230516122855
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: 08/12/2023
NARRATIVE
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Third allegation, Facility does not ensure staff are trained on medication assistance. LPA conducted a record review pertaining to staff training, LPA observed staff training's records pertaining to staff medication training. Due to a lack of information, the above allegations are deemed UNSUBSTANTIATED at this time.

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 Wellness Director Syrina Canez.

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

DATE: 08/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5