361880599-8-13-2021-18-AS-KCLS-C5YRVV-20210817132209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880599
Report Date: 08/13/2021
Date Signed: 08/13/2021 01:39:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/11/2020 and conducted by Evaluator Christine Le

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200811160731

FACILITY NAME:	LOTUS VILLA AND MEMORY CARE		FACILITY NUMBER:	361880599
ADMINISTRATOR:	DAY, FELISA N		FACILITY TYPE:	740
ADDRESS:	9448 CITRUS AVE		TELEPHONE:	(909) 355-6887
CITY:	FONTANA	STATE: CA	ZIP CODE:	92335
CAPACITY:	99	CENSUS: 22	DATE:	08/13/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Angelica Eleco		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Facility does not assist residents with ADL's.
Facility does not provide adequate supervision.
Facility did not safeguard resident's belongings.
Centrally stored medications were accessible to residents.
Facility did not change resident's linens for two months.
Facility does not have signal system.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Le conducted an unannounced visit to the facility to investigate the above allegations. LPA met with administrator Angelica Eleco.

LPA toured the facility, conducted interviews, and reviewed facility files. The first allegation indicates that the facility does not assist residents with ADL's such as feeding. LPA conducted interviews and in general it was reported that staff assist with residents with feeding as needed. The second allegation indicates that the facility does not provide adequate supervision. LPA conducted interviews and in general it was reported that staff check on the residents often especially as there is adequate staffing and a smaller amount of residents at this time. The third allegation indicates that the facility failed to safeguard Resident 1 (R1)'s belongings in 2020. LPA conducted interviews and in general it was reported that the resident's responsible party picked up the resident's belongings once the resident was ready to be discharged from the facility. LPA also reviewed R1's inventory of personal belongings dated 7/11/20 indicating the removal of the resident's items. Interviews also denied that another resident was using R1's bed while R1 was away from the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Christine Le	TELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200811160731

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 361880599
	VISIT DATE: 08/13/2021

NARRATIVE

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The fourth allegation indicates that centrally stored medications are accessible to the residents. LPA toured the facility and observed that centrally stored medications are kept locked and inaccessible in the medication room. Interviews in general reported that centrally stored medications are locked when not in use. The fifth allegation indicates that the facility did not change R1's linen for two months. LPA reviewed the laundry schedule and observed that the residents' linen are changed twice a week. LPA observed an adequate supply of linens at the facility. LPA conducted interviews and in general it was reported that the residents' linen are changed twice a week and more if needed. The sixth allegation indicates that the facility does not have a signal system. LPA toured the facility and observed that each resident room is equipped with a call pendant system for the resident to ask for assistance. The signal system links to the staff office where staff are made aware if a resident needs assistance. LPA observed that the signal system was functional. Interviews in general reported that staff respond to the signal system within five (5) minutes.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the administrator.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Christine Le	TELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

LIC9099 (FAS) - (06/04)

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