361880599-1-10-2024-56-AS-EMAN-CZZP2Y-20240131095640

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880599
Report Date: 01/10/2024
Date Signed: 01/10/2024 02:52:48 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-20230908111928

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:	0	CENSUS: 83	DATE:	01/10/2024
		UNANNOUNCED	TIME BEGAN:	01:48 PM
MET WITH:	Rebecca Parra		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Neglect resulting in un-explained injury.
Licensee failed to seek medical attention on a timely manner.

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 review of records.

First allegation, Neglect resulting in unexplained injury. During interviews and review of records, it was revealed that Resident #1 was non-ambulatory and complaining of pain on 9/2/2023. During interviews Staff #1 reported to LPA that Staff #2 had indicated that Resident #1 did not want to get out of bed and complained of pain. Staff #1 reported that facility staff placed Resident # 1 in a wheelchair. Staff #1 indicated to LPA that Resident #1 was taken to the hospital on 9/6/2023 upon the request of a Home-Health (Charter Health Care) nurse, who was providing health care services to Resident #1 at time. On 9/6/2023 upon hospital admission Loma Linda Hospital detected two blood clots on Resident #1 along with a broken femur. Upon interviews with staff, it was reported to LPA that facility was not aware of how Resident #1 obtained an unexplained injury at the facility.

Substantiated

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: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

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 3

Control Number 56-AS-20230908111928

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: 01/10/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Second allegation, Licensee failed to seek medical attention on a timely manner. During record review LPA observed that Resident #1 was non-ambulatory and complaining of pain on 9/2/2023. In addition, LPA observed that Resident #1 was taken to the hospital four (4), days later after the request was suggested from an outside care provider who was providing Home-Health care services to Resident #1. Based on the evidence gathered during the investigation, the above allegation is 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, “Personnel Requirements – General” 87411 (a), Incidental Medical and Dental Care 87465 (2), from division 6, chapter, Article 6, Article 04, is being cited on the attached LIC 9099 D.

An immediate civil penalty is assessed for $500.00, per Health and Safety Code 1548 (c). In addition, an additional review is being conducted and additional civil penalty may be imposed per Health and Safety Code 1569.49 (f).

Exit interview conducted and copy of report provided to Facility Administrator Rebecca Parra.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 56-AS-20230908111928

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: 01/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/11/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee agrees to have staff trained on being competent and recognizing resident health changes and provide the appropriate services necessary to meet resident needs. Proof of updated training for all staff shall be emailed to LPA Guerrero by Plan of Correction date of 1/11/24.
	8 9 10 11 12 13 14	Based on interviews, record review, the facility personnell did not ensure to provide the services necessary to meet Resident #1 needs, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
Type A 01/11/2024 Section Cited CCR 87465(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care (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 evidence by:	1 2 3 4 5 6 7	Licensee agrees to have staff trained on emergency responses and procedures to properly provide medical assistance to residents in care. Licensee is to submit a copy of the training to LPA Guerrero by Plan of Correction date of 1/11/24.
	8 9 10 11 12 13 14	Based on interviews and record review, the Facilty did not ensure that Resident #1 was provided medical care services on a timely manner, which poses an Immediate Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14

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 Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3