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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880599
Report Date: 12/18/2023
Date Signed: 12/18/2023 06:09:09 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
08/21/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230821115503
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:0CENSUS: 81DATE:
12/18/2023
UNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Rebecca ParraTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff caused injury to a resident in care.
Staff did not seek medical attention for a resident in care.
Staff did not notify resident's responsible party of an incident in a timely manner.
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 Administrator Rebecca Parra and explained the purpose of the visit. The investigation consisted of interviews and a review of records.

First allegation, Staff caused injury to a resident in care. LPA conducted an in-person interview with Resident #1 during observation LPA observed what appeared to be scrape marks on Resident #1 right hand. During interview with Resident #1 family member, it was reported that Resident #1 obtained scrape marks on right hand during fall. ***Personal Rights Substantial Violation is a cross reference towards fourth allegation (Staff choked a resident in care.)***

Second allegation, Staff did not seek medical attention for a resident in care. During record review LPA found that no record was on file pertaining to Resident #1 receiving medical treatment after the incident that pertained to Resident #1 falling after being pushed by facility staff. In addition, based on record review LPA observed Resident #1 to have dementia and diagnosed with seizures.
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: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
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-20230821115503
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: 12/18/2023
NARRATIVE
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Third allegation, Staff did not notify resident's responsible party of an incident in a timely manner. During interviews and record review LPA observed that facility did not inform Resident #1 responsible party of the incident in a timely manner. Based on title 22 reporting requirements, because of the nature of the incident facility needed to report within 24 hours of the occurrence of the incident. 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, Personal Rights 80072 (3); Reporting Requirements 87211 (2); Incidental Medical and Dental Care 87465 (2) 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, along with a copy of the appeal rights. 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: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 56-AS-20230821115503
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: 12/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2024
Section Cited
CCR
80072(3)
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Personal Rights 80072 (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of punitive nature, including but not limited to: interference with the daily living function, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication, or aids to physical functioning.

This requirement is not met as evidenced by:
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Administrator has agreed to read over the entire Personal Rights regulation and provide training to all staff regarding 80072 (3) regulation pertaining to inflicting corporal punishment to residents in care. Administrator will provide proof of training signed by all staff. On POC date 1/19/2024 and will email the document to assigned LPA.
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Based on observation, interviews and record review, the facility did not ensure Resident #1 to be free from corporal or unusual punishment, infliction of pain, which poses an immediate Health, Safety, or Personal Rights risk to persons in care
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Type B
01/19/2024
Section Cited
CCR
87465(2)
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Incidental Medical and Dental Care 87465 (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 evidenced by:
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Administrator has agreed to read over the entire Incidental Medical and Dental Care and provide training to all staff regarding 87465 (2) regulation pertaining to residents being provided care. Administrator will provide proof of training signed by all staff. On POC date 1/19/2024 and will email the document to assigned LPA.
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Based on, interviews and record review, the facility did not ensure Resident #1 was transported to the nearest hospital for further evaluation or was seen by local fire department after incident.
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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: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20230821115503
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: 12/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2024
Section Cited
CCR
87211(2)
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Reporting Requirements 87211 (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes, or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.

This requirement is not met as evidenced by:
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Administrator has agreed to read over the entire Reporting Requirements regulation and provide training to all staff regarding 87211 (2) regulation pertaining to proper reporting. Administrator will provide proof of training signed by all staff. On POC date 1/19/2024 and will email the document to assigned LPA.
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Based on, interviews and record review, the facility did not ensure Resident #1 was transported to the nearest hospital for further evaluation or was seen by local fire department after incident.
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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: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
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
08/21/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230821115503

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:CENSUS: 81DATE:
12/18/2023
UNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Rebecca ParraTIME COMPLETED:
06:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff choked a resident in care.
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 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.

Fourth allegation, Staff choked a resident in care. During interviews, review of records, along with video footage it was observed that staff did not choke Resident #1 but rather push Resident #1 with an open hand by the neck resulting in Resident #1 to fall back. Based on the available information, LPA found that the complaint allegation is 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 Administrator Rebecca Parra.
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: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
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