361880599-5-17-2022-56-AS-NBRN-CGJTV3-20220721150317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880599
Report Date: 05/17/2022
Date Signed: 05/17/2022 01:47:57 PM

Unsubstantiated

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
05/12/2022 and conducted by Evaluator Anna Bueno

COMPLAINT CONTROL NUMBER: 56-AS-20220512102447

FACILITY NAME:	LOTUS VILLA AND MEMORY CARE		FACILITY NUMBER:	361880599
ADMINISTRATOR:	DEBORAH P. HIGGINS		FACILITY TYPE:	740
ADDRESS:	9448 CITRUS AVE		TELEPHONE:	(909) 355-6887
CITY:	FONTANA	STATE: CA	ZIP CODE:	92335
CAPACITY:	99	CENSUS: 20	DATE:	05/17/2022
		UNANNOUNCED	TIME BEGAN:	10:34 AM
MET WITH:	Deborah Higgins		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Resident has fallen several times.
Staff are not meeting resident's needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility for the purpose of initiating and delivering findings on the above mentioned complaints. LPA met with administrator Deborah Higgins who was informed of the reason for today's visit. The investigation consisted of staff and resident interviews, observations, and documents review.

Allegation 1: Resident has fallen several times. It is alleged that resident is a fall risk. LPA observed residents ambulating in walking assistive devices and staff are always present in the hallways for resident assistance. The facility actively submits incident reports, such as falls, to the Department as required. This allegation is therefore unsubstantiated.
Allegation 2: Staff are not meeting resident's needs. It is alleged that the resident’s medical or physical needs are not being met. Interviews reveal that staff works with responsible parties in continually identifying resident's needs. Records reviewed shows that residents' partial bed rails are medically ordered. LPA observed all rooms to have call buttons for assistance and staff provides walkie talkies for immediate staff assistance.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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 56-AS-20220512102447

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: 05/17/2022

NARRATIVE

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A finding of UNSUBSTANTIATED means that 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 today's visit. An exit interview was conducted where this report was discussed and provided to administrator Deborah Higgins.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC9099 (FAS) - (06/04)

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