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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530102
Report Date: 04/13/2026
Date Signed: 04/13/2026 12:19:25 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
03/04/2026 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20260304110227
FACILITY NAME:LOTUS VILLA AND MEMORY CAREFACILITY NUMBER:
365530102
ADMINISTRATOR:HEATHER O'NEELFACILITY TYPE:
740
ADDRESS:9448 CITRUS AVENUETELEPHONE:
(909) 355-6887
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:99CENSUS: 96DATE:
04/13/2026
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mayra Alfaro-AdministratorTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Unqualified staff provide medical care to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Mayra Alfaro and explained the purpose of the visit regarding the allegations stated above.

First allegation: Unqualified staff provide medical care to residents. Regarding the allegation stated above, LPAs conducted interviews with Resident #1, Resident #2, Resident #3, and Resident #4, pertaining to the alleged allegation and three out of the four residents informed LPAs that they independently administer their own insulin as well as checking their own blood sugar. During further interview Resident #4 informed LPA that facility staff assists with the administration of insulin. Resident #4 further explained that the assistance is not hand over hand assistance but full injectable administration of insulin. Resident #4 also stated that the last administration done by staff was about a week ago. 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: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
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 5
Control Number 56-AS-20260304110227
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: 04/13/2026
NARRATIVE
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A finding that the complaint is Substantiated means that the findings are valid because the preponderance of the evidence standard has been met. Title 22 regulations Injections 87629 (a)(b)(1), from division 6, chapter, article 6, is, cited on the attached LIC 9099 D.

An exit interview was conducted where this report, appeal rights, and LIC9099-D was discussed, and a copy of the report was provided to Facility Administrator at the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20260304110227
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: 04/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/14/2026
Section Cited
CCR
87629(a)(b)(1)
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87629 Injections ....(a) The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional.....(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensees who admit or retain residents who require injections shall be responsible for the following: ....(1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance.

This requirement is not met as evidence by:
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The Licensee has agreed to read over: 87629 Injections (a)(b)(1), regulation and provide training to all staff who assist with the administration of medication. The licensee will ensure that all Medtech’s, Caregivers, have a clear understanding that ONLY appropriately skilled professionals are to administer injections to residents in care. The licensee will email LPA a copy of the signed training and acknowledged by all Med-Support by POC 4/14/2026.
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Based on interviews, the licensee did not adhere by regulation 87629, by permitting a non-skilled professional to administer insulin through injection to resident #4, which poses an immediate health, safety, or personal rights, risk to residents 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: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
03/04/2026 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20260304110227

FACILITY NAME:LOTUS VILLA AND MEMORY CAREFACILITY NUMBER:
365530102
ADMINISTRATOR:HEATHER O'NEELFACILITY TYPE:
740
ADDRESS:9448 CITRUS AVENUETELEPHONE:
(909) 355-6887
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:99CENSUS: 96DATE:
04/13/2026
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mayra AlfaroTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Facility staff are not ensuring the facility is free of bed bugs.
Facility staff are not allowing activities for residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Mayra Alfaro and explained the purpose of the visit regarding the allegations stated above.

First allegation: Facility staff are not ensuring the facility is free of bed bugs. Regarding the allegation stated above, on 3/4/2026, LPAs conducted an inspection in room 207 and observed no bedbugs to be present. LPAs interviewed two residents occupying Room 207, LPAs went over the alleged allegation with residents, and both residents reported that in the past they were relocated to other rooms because of bedbugs however, residents stated that their rooms were treated and there has not been a report of bedbugs since. During review of records LPAs discovered that on 10/7/2025, it was reported that Units #114, #205, 206 and as a precaution Units #116, 204, 207, 208, 203 on second floor were treated for bedbugs. In addition, LPAs observed that the last treatment was completed on 10/24/2025, with no additional reports of bedbugs.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20260304110227
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: 04/13/2026
NARRATIVE
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LPAs conducted interviews with staff who reported that in the past the facility was treated for bedbugs, however, currently there has not been any reports regarding bedbugs.

Second allegation: Facility staff are not allowing activities for residents in care. Regarding the allegation stated above, LPAs conducted interviews with Staff #1, Staff #2, Staff #3, and Staff #4, regarding the alleged allegation Staff #1 informed LPAs that Memory Care Unit located on the second floor take qualified residents out for walks three times a day. In addition, Staff #1-4 informed LPAs that activities in memory care are always completed and all activities are also witnessed as residents in memory care must be escorted and accompanied by one or two staff members. Based on corroborating evidence LPA has determined that the above allegations are 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.

In addition, during the inspection LPAs observed that on 3/4/2026 the facility had a census of 92 and was on compliance and not exceeding the capacity of 99.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Mayra Alfaro.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5