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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530102
Report Date: 08/20/2025
Date Signed: 08/20/2025 12:04:38 PM

Substantiated


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
04/16/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240416172928
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: 94DATE:
08/20/2025
UNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Heather O'NeelTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Facility staff are not administering residents’ insulin as prescribed.
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 Heather O’Neel and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records.

First allegation: Facility staff are not administering residents’ insulin as prescribed. Regarding the allegation LPA conducted interviews with Staff #1 and Staff #2, provided LPA with a verbal admission, that R#1 did not receive insulin medication because R#1 insulin could not be located. S#1 and S#2 informed LPA that R#1 insulin medication was later located and found to be inside Med-room refrigerator. Because R#1 insulin was not located and found several days later R#1 was not able to receive their medication as prescribed. Based on the evidence gathered during the investigation, the above allegation is Substantiated.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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 6
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
04/16/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240416172928

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: 94DATE:
08/20/2025
UNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Heather O'NeelTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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9
Resident was injured while in care.
Resident did not have access to phone while in care.
Facility staff did not adequately clean resident’s bathroom.
Facility is in disrepair.
Facility staff did not follow resident's diabetic diet.
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 Heather O’Neel and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records.

First allegation: Resident was injured while in care. Regarding the allegation stated above LPA conducted interviews with Staff #1-3 who informed LPA that R#1 was listed as a fall risk. In addition, S#1-3 informed LPA that R#1 was able to use a walker and wheelchair to self-transfer. S#1-3 informed LPA that R#1 sustained an unwitnessed fall due to R#1 attempting to get out of bed without calling staff for assistance. S#1-3 informed LPA that R#1 was evaluated and transported to local hospital for further evaluation. LPA conducted an inspection in R#1 room and observed a poster that indicated that R#1 was a fall risk in addition, LPA observed a phone/call light to be next to R#1 bed LPA tested and witnessed that R#1 call light was in working condition. LPA conducted an interview with R#1 who informed LPA that at the time that R#1 sustained the fall R#1 was attempting to get out of bed to utilize the bathroom when resident felt dizzy and fell. R#1 informed LPA that resident did not call for assistance at the time of the incident.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 56-AS-20240416172928
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: 365530102
VISIT DATE: 08/20/2025
NARRATIVE
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Second allegation: Resident did not have access to phone while in care. Regarding the allegation LPA conducted interviews with Staff#1-3 who informed LPA that resident #1 was in room #105 however, was transferred to 2nd floor Room#208 because R#1 phone/call light was not in working condition and because of that matter R#1 was relocated. LPA conducted a room inspection and observed that R#1 had access to a phone in addition, LPA inspected R#1 phone/call-light and discovered that R#1 phone was in working condition during the time of the inspection.

Third allegation: Facility staff did not adequately clean resident’s bathroom. Regarding the allegation LPA conducted interviews with S#1-3 who informed LPA that on different occasions housekeeping has attempted to clean R#1 room however, R#1 refused for housekeeping to clean R#1 room. S#1-3 informed LPA that conversations with R#1 regarding safety precautions were held however, staff indicated that R#1 refused. LPA conducted a walkthrough in R#1 room LPA observed room to be in standard LPA inspected R#1 bathroom and observed bathroom to be in standard in addition, LPA observed that all bathroom fixtures were in working condition. LPA conducted interviews with Staff #1-3 who informed LPA that residents rooms along with bathrooms get cleaned daily. LPA conduced interviews with Resident #2-4 regarding housekeeping and all residents informed LPA that they have no issues pertaining to their bathrooms or rooms. R#2-4 informed LPA that their bathrooms get cleaned daily by housekeeping.

Fourth allegation: Facility is in disrepair. Regarding the allegation stated above LPA conducted a walkthrough of the facility first and second floor, during the walkthrough LPA observed facility to be clean and free of clutter. During the walkthrough LPA observed that the inside of the facility was in good repair LPA observed that all safety features in the facility were in working condition. LPA conducted a walkthrough of the outer perimeter of the facility and observed that the outer perimeter was in good repair.

Fifth allegation: Facility staff did not follow resident's diabetic diet. Regarding the allegation LPA conducted interviews with S#1-3 who informed LPA that R#1 was on a diet order based on resident diabetic diet. S#1-3 informed LPA that InnoVage would send the facility a new diet order if any changes will occur. S#1-3 informed LPA that meal orders are provided to kitchen who then follow all resident’s meal plans based on each resident[s] requirements. During review of records LPA observed that R#1 was on a regular texture with a diabetic plan.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 56-AS-20240416172928
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: 365530102
VISIT DATE: 08/20/2025
NARRATIVE
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Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated.

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 (LIC 9099) was discussed, and a copy was provided to Facility Administrator Heather O’Neel at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 56-AS-20240416172928
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: 365530102
VISIT DATE: 08/20/2025
NARRATIVE
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Substantiated; A finding that the complaint is Substantiated means that the residents’ is valid because the preponderance of the evidence standard has been met. Title 22 regulations 87465(a)(2), incidental medical and dental care from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights to Facility Administrator Heather O’Neel.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 56-AS-20240416172928
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: 365530102
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/21/2025
Section Cited
CCR
87465(a)(2)
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Incidental Medical and Dental Care
(a) ....A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:.....(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidence by:
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Licensee has agreed to read over the Incidental Medical and Dental Care(a)(2) and provide training on medication management along with the storing of medication. Training will be emailed and provided to LPA Guerrero by POC date 8/29/2025.
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Based on observation, interviews, and record review, the licensee did not ensure to follow "Incidental Medical and Dental Care" for R#1 who did not receive medication on time, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6