361880599-3-22-2023-56-AS-EMAN-CR2S84-20230419133827

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880599
Report Date: 03/22/2023
Date Signed: 03/22/2023 01:09:23 PM

Unsubstantiated

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
03/01/2023 and conducted by Evaluator Paola Guerrero

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230301122253

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: 40	DATE:	03/22/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Rebecca Parra		TIME COMPLETED:	01:09 PM

ALLEGATION(S):

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Resident sustained an un-explained injury from a fall while in care
Staff did not properly report incidents involving a resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator Rebecca Parra and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, resident sustained unexplained injury while in care. S1, S2, S3, stated that on 3/1/23 R1 received a gash on back of R1 head. S1 stated that R1 was immediately assessed and transported ER. LPA asked S1 if documentation was provided regarding R1 S1 and S2 stated that an SIR was sent to licensing on 3/1/23 and family was also informed. S1, S2, and S3, stated that facility footage shows how R1 received gash on back of R1 head. LPA reviewed footage on 3/2/23 and observed that R1 was standing and looking outside window when knees locked causing R1 to fall back and injure the back of R1 head. LPA observed via footage that Med team immediately responded to R1 aid and provided R1 with care. S1, S2, S3, stated upon residents return that a fall risk assessment will be conducted for R1.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

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-20230301122253

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: 03/22/2023

NARRATIVE

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Second allegation, staff did not properly report incidents involving a resident.

It was also reported facility staff allegedly did not report R1's incidents involving resident. RP reported that incident that occurred on 1/11/2023 was not reported to R1 responsible party. R1's Special Incident Reports (SIR), pertaining to R1’s incidents were provided. LPA observed that each documentation pertaining to R1’s incidents demonstrate the dates R1,s falls occurred and parties that were notified. The first report shows a slip/fall occurred on 1/11/23 SIR states Administrator along with responsible party (POA), was notified. The second occurrence shows slip/fall occurred on 1/28/23 SIR states Administrator was notified along with responsible party (Family member), The third occurrence shows slip/fall occurred on 3/1/23 SIR states Administrator was notified along with responsible party (Family Member), due to a lack of information, allegations are UNSUBSTANTIATED at this time.

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 was discussed and provided to Facility Administrator Rebecca Parra.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC9099 (FAS) - (06/04)

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