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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530102
Report Date: 08/30/2023
Date Signed: 08/30/2023 02:53:57 PM


Document Has Been Signed on 08/30/2023 02:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
365530102
ADMINISTRATOR:PARRA, REBECCAFACILITY TYPE:
740
ADDRESS:9448 CITRUS AVENUETELEPHONE:
(909) 355-6887
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:99CENSUS: 70DATE:
08/30/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Eli GolmanTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Paola Guerrero and Ryan Gardner conducted an announced pre-licensing visit to facility. LPAs met with Facility Operation Manager Eli Goldman. The pending application is for a Residential Care Facility for Elderly (RCFE) for ninety-three (93)- non ambulatory and six (6) bedridden.

Operation Manager accompanied LPAs on a tour of the inside and outside of the facility. During today’s inspection the following areas need corrections:

Physical Plant/Environmental Safety - x2 lights in dining room #1 not working; x1 lights not working in dining room #2. Second floor outside room #214 partially collapsing. X2 broken windows on 2nd floor. Hallway light missing cover. Second floor entry door to staff break room had battery exposed on auditory device. Water temperature in rooms is below temperature lowest reading 85.1 F highest 96.6 F. Main restroom near dining room#1 hot water not working. Dining Room #1 emergency exit was blocked with chairs and door was locked. Memory Lounge Room exit door was blocked with recliner chair. Outside gate was locked with master lock. Laundry Room was unlocked, unsecure bleach was left in laundry room, maintenance room was unlocked, exposed chemical (fabuloso) was left unsecure. Master lock in placed on exterior gate. Lock was removed during inspection. During inspection LPA observed master lock on exterior gate. Licensing was not notified exterior locks will be placed on exterior gate door. CCL office has not received approval of exterior lock being placed on exterior gate door. total of six non-auto closing fire doors were propted open with door stoppers. Dementia care unit does not have auditory devices on windows.

Personnel Records/Staff - 1 out 5 Caregivers missing CPR trainings in personnel record. Caregivers are associated to facility and cleared; however, criminal record clearance is not in personnel records.

During todays visit, the facility was issued seven (8) deficiencies.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/30/2023 02:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 365530102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with personal accommodations and by blocking interior emergency door exits with a dining room chair and a reclining chair; in, addition LPA observed a master lock on exterior exit gate which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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Facility Operation Manager Cleared POC during inspection. Removed lock; removed chairs from emegency exits.
Type A
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with personnel Records 1 out 5 Caregivers missing CPR trainings in personnel record which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
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S#1 cannot provide care to residents without completing CPR training. Administrator will submitt documented proof indicating that S#1 has been enrolled on CPR training by POC date 8/31/23. In addition, Administrator will submit proof of training once training has been completed.
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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/30/2023 02:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 365530102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section maintenance and operation; x2 lights in dinning room #1 not working; x1 lights not wokring in dining room #2. Second floor outside room #214 partially collapsing. X2 broken windows on 2nd floor. Hallway light missing cover. Second floor entry door to staff break room had battery exposed on auditory device which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Administrator will provide invoices, from a licensed contractor noting when the repairs will be taking place. Administrator will also cone off and post caution signage do not enter area below roof for safety precautions to residents. Administrator will provide pictures of signage in danger area. POC will emailed to assigned LPA on POC date 9/29/23.
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the lincensee did not comply with the section maintenance and operation; Water temperature in rooms are below temperature, lowest reading 85.1 F highest 96.6 F. Main restroom near dining room#1 hot water not working temperature reading was at 76.5 F and dining room #2 sink was broken (No hot running water) not allowing LPA to measure water temperature which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Administrator will provide invoices, noting maintenance repairs for bellow hot water temperature and sink repair in kitchen room on second floor. With no water running on hot side of the sink. Administrator will provide proof of maintenance repairs to assigned LPA on POC date 9/29/23.
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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 08/30/2023 02:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 365530102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the storage pace section. Laundry Room on assisted living side was unlocked, unsercure bleach was left in laundry room, maintanence room was unlocked, exposed chemical (fabuloso) was left unsecure. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Licensee shall provide training on how to properly main toxic chemicals secured when chemicals not being utilzed. Licensee will provided ackowledgement and signed training on how to manage and secure toxic chemicals by POC date 9/29/2023
Type B
Section Cited
CCR
87355(j)
Criminal Record Clearance
(j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file as required in Section 87412, Personnel Records.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above; caregivers are associated to facility and cleared however, criminal record clearance is not in personnel records.which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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Administrator printed criminal record clearance from guardian for S#2, S#3, and S#4. Administrator agreed to keep the required documentation on file for all personnel records going forward. POC was cleared during visit
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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 08/30/2023 02:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 365530102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)
87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section Care of Persons with Dementia; By not having auditory devices on windows which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
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Administrator shall provide CCL department a plan of implementing audio devices on every window in the dementia care unit. Plan shall be completed by POC date 8/31/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 365530102
VISIT DATE: 08/30/2023
NARRATIVE
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Pre-licensing is incomplete with deficiencies to be resolved by 9/29/23. A follow-up pre-licensing visit will be scheduled upon resolution of deficiencies.

An exit interview was conducted, and a copy of this report was provided to Facility Operation Manager Eli Goldman.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 08/30/2023 02:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 365530102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section fire safety; total of six non-auto closing fire doors were propted open with door stoppers, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
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During the visit administrator closed all six non- auto closing fire doors. Administrator will send LPA fire safety training regarding non-auto closing doors as acknowlegement.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
LIC809 (FAS) - (06/04)
Page: 7 of 7