<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880599
Report Date: 02/02/2024
Date Signed: 02/02/2024 02:34:45 PM


Document Has Been Signed on 02/02/2024 02:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
361880599
ADMINISTRATOR:REBECCA PARRAFACILITY TYPE:
740
ADDRESS:9448 CITRUS AVETELEPHONE:
(909) 355-6887
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:0CENSUS: 88DATE:
02/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Rebecca ParraTIME COMPLETED:
02:34 PM
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
Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced case management visit during complaint control number 56-AS-20230426144154. LPA met with Facility Administrator Rebecca Parra and explained the reason for the visit.

LPA Guerrero observed Staff #1 with criminal background clearance, but the facility failed to transfer Staff #1 to the facility. Administrator Rebecca Parra confirmed with LPA Guerrero that Staff #1 is no longer employed with the facility. LPA informed Rebecca that a deficiency will be issued as this pose potential health, safety and personal rights risks to residents in care.

A civil penalty of $100 for criminal record clearance was assessed for Staff #1 working at the facility with criminal background clearance but the facility failed to transfer and associate Staff #1 to the facility.

An exit interview was conducted where this report, LIC809, along with LIC809D, LIC421BG and Appeal Rights were discussed and provided to Administrator Rebecca Parra.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/02/2024 02:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/05/2024
Section Cited
CCR
87355(e)(2)

1
2
3
4
5
6
7
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working...(2) Request a transfer of a criminal record clearance... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator has agrred to train all staff on CCR 87355(e)(2) and submit proof of Training Log to LPA guerrero by POC due date 2/5/2023.
8
9
10
11
12
13
14
Based on observation, interview and records review, the Licensee did not comply with the section cited above by failing to trasfer the criminal backround clearance for Staff #1 before allowing staff to work at the facility which pose potential health, safety and personal rights risks to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2