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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880599
Report Date: 09/20/2023
Date Signed: 09/20/2023 01:37:37 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
09/08/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230908105412
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: 69DATE:
09/20/2023
UNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Rebecca ParraTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff are not cleaning resident's wheelchair
Staff inappropriately used resident's shirt to clean the floor.
Staff are not cleaning the facility.
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 Administrator Rebecca Parra and explained the purpose of the visit. The investigation consisted of interviews and a review of records.

First allegation, Staff are not cleaning resident's wheelchair. During interviews with Staff #1 Staff #2 and Staff #4 stated that both arm rest of Resident #1 wheelchair gets wiped down however, Staff #1, Staff #2, and Staff #4 stated that the rest of Resident #1 wheelchair does not get clean, staff also stated that they were not aware that Resident #1 wheelchair needed to be cleaned as they have not witnessed other staff clean Resident #1 wheelchair. LPA reviewed Resident #1 Physician report and observed that Resident #1 is non-ambulatory and utilizes a wheelchair to ambulate around the facility. LPA reviewed Resident #1 Admission Agreement “Basic services” which indicates “residents basic services will be made available to all residents according to residents needs on pre-admission appraisal.”

Second allegation, Staff inappropriately used resident's shirt to clean the floor. During interview with
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: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
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 6
Control Number 56-AS-20230908105412
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: 09/20/2023
NARRATIVE
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outside party, outside party stated witnessing Staff #3 utilizing Resident #1 shirt to wipe wet floor in resident’s room. During interview with Staff #3 staff denied utilizing Resident #1 shirt to wipe off the wet floor in resident's room. Staff #3 however, stated that a bed sheet that belongs to Resident #1 was used to wipe off the wet floor in resident’s room. LPA mentioned to Staff #3 that a bedsheet is also considered residents personal property and should not be utilized for those circumstances.

Third allegation, Staff are not cleaning the facility. During facility walk-through LPA observed facility floors in first floor to be sticky and not moped by housekeeping. In addition, LPA observed restroom toilet in second floor to be dirty and trash not taken out. Staff #1 indicated that restroom was clogged but was not sure for how long. Based on the evidence gathered during the investigation, the above allegations are Substantiated.

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, 87464 (d) Basic Services, 80072 (1) Personal Rights, 87303 (a) Maintenance and Operation 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 Facility 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: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
09/08/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230908105412

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: 69DATE:
09/20/2023
UNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Rebecca ParraTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
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8
9
Staff left resident in a soiled diaper for an extended period of time.
Staff made inappropriate comments towards resident.
Staff are not cleaning resident's room.
Staff are not able to meet resident's needs.
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 Administrator Rebecca Parra and explained the purpose of the visit. The investigation consisted of interviews and a review of records.

First allegation, Staff left resident in a soiled diaper for an extended period of time. During interviews with morning staff, Staff #1, and Staff #2, both staff stated that Resident #1 diaper gets changed twice in the morning and then routine checks are completed. Staff #2 stated that the last round of diaper check is completed at 8:00pm right before the next start of shift. Before interviews were conducted LPA observed Staff #1 and Staff #2 changing Resident #1 inside Resident’s room.

Second allegation, Staff made inappropriate comments towards resident. During the interview with the outside party, outside party stated overhearing inappropriate comments being said about Resident #1 by Staff #3.
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: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
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 6
Control Number 56-AS-20230908105412
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: 09/20/2023
NARRATIVE
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During the interview with Staff #3 staff denied making inappropriate comments towards Resident #1. Staff #3 stated that inappropriate comments were not made towards the resident. Staff #3 stated a comment was made to another staff member as an indication that Staff #3 needed help from another staff member to prevent an injury from occurring. During interviews staff denied overhearing Staff #3 make inappropriate comments in reference to Resident #1.

Third allegation, Staff are not cleaning resident's room. LPA conducted a walk through of Resident # 1 room, LPA observed Resident #1 is a shared room. LPA observed that both beds were made in addition, LPA observed that both night stands were organized and free of clutter, LPA also observed residents’ room floor clean. During interview with Staff #1 and Staff #2 both stated that housekeeping cleans resident’s rooms often.

Fourth allegation, Staff are not able to meet resident's needs. During interviews with: Staff #1, Staff #2, and Staff #4, deny not being able to meet residents needs Staff #1, Staff #2, and Staff #4 stated that staff needs are being met daily according to each residents’ individual needs and services. LPA observed between Staff #1 and Staff #2 providing and completing Resident #1 needs and services. Based on the evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated.

Unsubstantiated; meaning that although the allegations 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 (LIC 9099) was discussed, and a copy was provided to Facility 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: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 56-AS-20230908105412
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: 09/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2023
Section Cited
CCR
87464(d)
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Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources...
This requirement is not met as evidence by:
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Licensee has agreed to read over basic services regulations and submit a signed acknowledgment of understanding that indicates the understanding of the basic services to a client by POC date 10/13/2023. POC will be emailed to assinged LPA.
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Based on observation, inerviews and record review, the licensee did not ensure residents basic services to be met, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type B
10/13/2023
Section Cited
CCR
87303(a)
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Maintenance and Operation...
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidence by:
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Licensee has agreed to read over regulation and ensure facility is maintain clean at all times. Licensee will submit a written acknowledgement of understanding signed by housekeeping staff understanding the Maintenance and Operation regulation. POC will be emailed to CCL assiged LPA on 10/13/2023
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Based on observation, inerviews and record review, the licensee did not ensure facilithy to be clean at all times as stated in regulation, 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: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 56-AS-20230908105412
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: 09/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2023
Section Cited
CCR
80072(1)
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Personal Rights
(1) To be accorded dignity in his/her personal relationship with staff and other persons.

This requirement is not met as evidence by:
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Licensee will provide a signed acknowledgement of understanding singed by all staff stating the they have read and understand Personal Rights regulations by POC due date of 10/13/2023
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Based on observation, interviews and record review, the lincensee did not ensure residents personal rights to be followed, which poses an immediate Health, Safety, or Personal Rights rist 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: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6