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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880599
Report Date: 02/02/2024
Date Signed: 02/02/2024 02:30:17 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
04/26/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230426144154
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
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Rebecca ParraTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident sustained unexplained injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Rebecca Parra and explained the purpose of the visit regarding the allegation listed above.

The Department determined, based upon investigation, that the facility did not provide care and supervision to protect R1’s health and safety when R1 fell on April 24, 2023.
Facility records revealed that R1 was a fall risk upon admission in July 2022. Since admission, R1 sustained two falls, first fall was recorded on 7/29/2022, in which R1 complained about head pain and feeling dizzy. Second fall occurred on 4/24/2023, in which R1 sustained head injury. In addition, it was found that R1s medical conditions and medications that R1 was taking, increase R1 risk for falls. Following initial and subsequent falls, facility staff did not implement a plan of care to minimize R1’s risk for future falls. Furthermore, staff interviews revealed that not all were aware of R1 fall risk nor were all aware of R1 conditions.
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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 56-AS-20230426144154
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: 02/02/2024
NARRATIVE
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 Interviews found that on April 24, 2023, Staff 1 (S1) was escorting R1 with one hand out of R1 room. As S1 reached with the other hand to open the door, R1 reportedly “made a grunting noise” and immediately fell backward toward the floor. S1 reported that blood was seen coming from head area that hit the floor. Emergency medical services were contacted and R1 was transported to the hospital. R1 sustained a head injury, identified per medical records as Subarachnoid Hemorrhage. Based on the Department investigation gathered during 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.

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 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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 56-AS-20230426144154
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: 02/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/05/2024
Section Cited
CCR
87411(a)
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Personnel Requirements- General 87411 (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:
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Administrator has agreed to read over the entire Personnel Requirement- General regulation and provide training to all caring support staff. Administrator will email LPA Guerrero a copy of the training which will be signed and dated by all staff by POC date 2/5/2024.
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Based on, interviews and record review, facility did not ensure facility personnel to be competent to provide the services necessary to meet Resident #1 needs.
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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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
04/26/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230426144154

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
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Rebecca ParraTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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2
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Staff lock residents in their room
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Rebecca Parra and explained the purpose of the visit regarding the allegation listed above.

Second allegation, Staff lock residents in their room. During interviews and observation, LPA observed that all residents room doors appeared to be commercial fire doors, which can be locked however, allows egress. During interview with residents all residents denied being locked in their rooms by staff. Based on the evidence obtained during the course of the investigation, LPA has determined that the above allegations 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 at the end of the visit.

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: 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.
LIC9099 (FAS) - (06/04)
Page: 4 of 4