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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880599
Report Date: 04/27/2021
Date Signed: 04/27/2021 04:48:23 PM

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
RIVERSIDE, CA 92507
FACILITY NAME:LOTUS VILLA AND MEMORY CAREFACILITY NUMBER:
361880599
ADMINISTRATOR:JEFFERY (JEFF) A. GOLLIHARFACILITY TYPE:
740
ADDRESS:9448 CITRUS AVETELEPHONE:
(909) 355-6887
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:99CENSUS: 25DATE:
04/27/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Celeste Williams - AdministratorTIME COMPLETED:
04:30 PM
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An Informal Meeting was conducted today via Zoom due to COVID-19 in order to discuss the facility's overall progress and operation. Persons present at today’s meeting were: Licensing Program Manager (LPM) Joel Esquivel, Licensing Program Analyst (LPA) Crystal Colvin, Administrator Celeste Williams, Gordhan Patel representing Licensee KP Health Care Group INC, and representatives for Meridian Hospice and Kindred Hospital.

Below are the topics that were addressed during the Informal Meeting Zoom Call:

· Facility Admitting Adult Residents (under 59 years old)
· Hospice Issues - Restricted & Prohibited Health Conditions
· Admission of Bedridden Residents - Fire Clearance for Non-Ambulatory Only
· Administrator Documentation to be Submitted for New Administrator

The facility representatives were instructed to not admit any bedridden residents without first contacting LPA Colvin, and to not admit any additional residents under the age of 59 without express permission from LPA Colvin or Community Care Licensing. Facility was instructed to submit an Administrator Packet for the facility's new Administrator, Celeste Williams. LPA Colvin additionally recommended that the facility submit documents to request a change in ambulatory status for the facility, to allow bedridden residents.

LPM Joel Esquivel and LPA Crystal Colvin offered the facility a referral to the Technical Support Program (TSP) Assistance. Licensee representative Gordhan Patel accepted the referral to the TSP Assistance.

An exit interview was conducted, and a copy of this report was provided via email to Administrator Celeste Williams for signature.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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