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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530102
Report Date: 11/15/2023
Date Signed: 11/15/2023 01:29:55 PM


Document Has Been Signed on 11/15/2023 01:29 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: 80DATE:
11/15/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Eli GoldmanTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPA) Paola Guerrero conducted an announced pre-licensing visit to facility. LPA met with Operations Manager Eli Goldman. The pending application is for a Residential Care Facility for Elderly (RCFE) capacity (99) current census (80). Operations Manager accompanied LPA on a tour of the inside and outside of the facility. The physical plant, in general, was in good repair. The buildings and grounds are free from hazards. The indoor and outdoor passageways are free of obstruction. There are no pools, bodies of water, firearms, or ammunition. All residents bedrooms are furnished with a bed, nightstand, dresser, and chair. All bedrooms have adequate lighting for resident use. Bathroom's toilet, shower and tubs are in good repair and have non-skid mats. LPA measured and observed the water temperatures in the bathrooms to be at 105.3 degrees F. All appliances are clean and operating properly. There is a sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present. Facility yard is completely enclosed with functioning gate with alarm system to exit to front yard. The outdoor space is suitable for client use. LPA observed fully charged fire extinguisher present in the facility. Smoke alarms and carbon monoxide are present and functional. Facility has a designated area (Med-Room) where medications are stored and locked. The facility had a designated area where staff and resident records are stored. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There is adequate seating in the common areas. Facility had a supply of activities for the clients.

Pre-licensing inspection is complete, and no corrections are needed to be made. The Comp III presentation was completed during today's visit.

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

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
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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