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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880599
Report Date: 01/04/2022
Date Signed: 01/04/2022 11:53:39 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
361880599
ADMINISTRATOR:BREANNA GUTIERREZFACILITY TYPE:
740
ADDRESS:9448 CITRUS AVETELEPHONE:
(909) 355-6887
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:99CENSUS: 20DATE:
01/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Heather RobinsonTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Administrator Heather Robinson and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Administrator Heather Robinson. The facility has a Mitigation Plan which was submitted last 10/12/2021.
LPA Brown observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information for the residents. LPA Brown toured the facility's resident bedrooms and bathrooms and observed that both resident bathrooms have paper towels and hand soap.

LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply, which is stored in the storage office. LPA Brown observed the facility to have a 30-day supply of gloves, masks, sanitizer, face shields and isolation gowns.

LPA Brown went over the various recommended training for facility staff with Administrator Robinson in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE. LPA Brown inquired as to if staff have been fit tested for N95 masks, and Administrator Robinson informed LPA Brown that at this time staff have not been fit tested. LPA Brown will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks.

**** continuation on LIC809C ****

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/04/2022
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LPA Brown will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. Additionally, most residents have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown will be providing Administrator Robinson with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

LPA Brown inquired about if the facility is still conducting COVID-19 surveillance testing of their staff members. Administrator Robinson informed LPA Brown that staff have continued to be tested at least every two weeks for COVID-19. LPA Brown additionally informed Administrator Robinson of the new PIN (PIN 21-32-ASC) and advised that as of 8/9/21, the new guidance for facilities will be to resume COVID-19 testing for staff, due to the increase of COVID-19 cases. In addition to going over the facility's policy for testing staff and residents for COVID-19, LPA Brown also inquired about if the facility is still screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Administrator Robinson confirmed that staff will continue to monitor residents’ symptoms, and that staff are screened for COVID-19 symptoms prior to entering the facility. LPA Brown additionally observed a temperature log kept by the facility where all temperatures for staff and residents are taken and recorded daily. Moreover, LPA Brown confirmed that the facility are verifying their visitors vaccination status as well.

Throughout today's inspection, LPA Brown observed all staff wearing masks. LPA Brown additionally observed residents not wearing a mask, and LPA Brown advised Administrator Robinson to encourage the residents to wear masks when in common areas indoors, though they cannot be forced.

An exit interview was conducted with Administrator Heather Robinson and a copy of this report and LIC9102 TA Advisory Notes were provided.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
LIC809 (FAS) - (06/04)
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