361880599-3-28-2022-56-AS-EMAN-CDTNGV-20220425102746

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880599
Report Date: 03/28/2022
Date Signed: 03/28/2022 10:51:29 AM

Substantiated

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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/23/2022 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220323143416

FACILITY NAME:	LOTUS VILLA AND MEMORY CARE		FACILITY NUMBER:	361880599
ADMINISTRATOR:	HEATHER ROBINSON		FACILITY TYPE:	740
ADDRESS:	9448 CITRUS AVE		TELEPHONE:	(909) 355-6887
CITY:	FONTANA	STATE: CA	ZIP CODE:	92335
CAPACITY:	99	CENSUS: 22	DATE:	03/28/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator Deborah Higgins		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Licensee refused to accept client back into care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 03/28/2022 at 09:30 AM to investigate a complaint and deliver the findings for the above complaint allegation. Upon arrival, LPA Brown met with Administrator Deborah Higgins, and LPA Brown informed Administrator Higgins of the purpose of the visit.

The investigation consisted of file review and interviews with relevant parties. LPA Brown conducted interviews, and reviewed facility files. The allegation indicates Licensee refused to accept client back into care. S1 reported that the facility cannot accept resident 1 (R1) back from the hospital because the facility is not appropriate for the resident since R1 has a need not previously identified. Per interviews and file review, LPA Brown observed that the facility did not accept R1 back from the hospital three (3) days after being notified of R1's discharged. LPA Brown will be issuing a citation.
*** Continuation in LIC9099C ***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

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-20220323143416

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
, CA 92507

FACILITY NAME: LOTUS VILLA AND MEMORY CARE	FACILITY NUMBER: 361880599
	VISIT DATE: 03/28/2022

NARRATIVE

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Based on LPA Brown's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore, the allegation of Licensee refused to accept client back into care is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC9099D.

An exit interview was conducted where this report (LIC 9099), LIC9099D, and Appeal Rights were discussed and provided to Administrator Deborah Higgins.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 56-AS-20220323143416

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
, CA 92507

FACILITY NAME: LOTUS VILLA AND MEMORY CARE	FACILITY NUMBER: 361880599
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/28/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/04/2022 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required ... Licensee did not meet this requirement as evidenced by:	1 2 3 4 5 6 7	Licensee stated to review Title 22, Section 87224(a) and write a self certification that the regulation has been read and is understood. Submit Proof of correction to LPA Brown by POC due date.
	8 9 10 11 12 13 14	Based on interviews, record review and observations, the Licensee refused to accept R1 back to the facility upon hospital discharge. This posed a potential Health, Safety or Personal Rights risk 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 Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

LIC9099 (FAS) - (06/04)

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