361880599-10-13-2023-56-AS-EMAN-CX5SAM-20231031134234

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880599
Report Date: 10/13/2023
Date Signed: 10/13/2023 11:05:31 AM

Unsubstantiated

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
06/28/2023 and conducted by Evaluator Paola Guerrero

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230628114139

FACILITY NAME:	LOTUS VILLA AND MEMORY CARE		FACILITY NUMBER:	361880599
ADMINISTRATOR:	REBECCA PARRA		FACILITY TYPE:	740
ADDRESS:	9448 CITRUS AVE		TELEPHONE:	(909) 355-6887
CITY:	FONTANA	STATE: CA	ZIP CODE:	92335
CAPACITY:	99	CENSUS: 71	DATE:	10/13/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Stacy Lopez		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Inadequate staffing to meet resident needs.
Resident sustained unexplained bruises.

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 Manger Stacy Lopez and explained the purpose of the visit. The investigation consisted of interviews and a review of records.

First allegation, Inadequate staffing to meet resident needs. During record review LPA observed updated facility staffing roster and observed facility to have sufficient staffing to meet resident needs. In addition, during facility record review LPA observed that facility utilizes a third-party staffing agency (Great comfort home care of California), to fill staffing need when needed.

Second allegation, Resident sustained unexplained bruises. During record review LPA observed that Resident #1 had two unwitnessed falls (6/19/2023 and 6/27/2023). LPA review Resident #1 needs and services plan and observed that Resident #1 was listed as a fall risk. In addition, based on the information listed LPA observed that it was discussed that Resident#1 may need to be transferred to a one-on-one care or rehab.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20230628114139

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: 10/13/2023

NARRATIVE

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LPA conducted interviews with residents and interviews with facility staff and revealed that there was no evidence of staff causing bruising to the residents in care. Residents denied being hit, pushed, physically injured, and or bruised by the staff. Facility staff denied hitting, pushing, causing injuries, and or bruising the residents. 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 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 (LIC 9099) was discussed, and a copy was provided to Facility Manger Stacy Lopez at the end of the visit.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC9099 (FAS) - (06/04)

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