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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530102
Report Date: 07/07/2026
Date Signed: 07/07/2026 02:11:34 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
07/06/2026 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20260706152847
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: 94DATE:
07/07/2026
UNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Desiree Martinez- MedTechTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility is not reporting resident incidents to resident responsible party.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Paola Guerrero and Matthew Aguilar arrived at the facility to deliver investigative findings. LPAs met with Facility MedTech Desiree Martinez and explained the purpose of the visit regarding the allegation stated above.

First allegation: Facility is not reporting resident incidents to resident responsible party. Regarding the allegation stated above, LPAs conducted interviews with Staff #1 and Staff #1 regarding the alleged allegation. Staff #1 informed LPAs that on 6/6/2026 and 6/7/2026 Resident #1 had sustained two falls, one in which was witnessed and the second was unwitnessed. Staff #1 further explained that both falls were not reported to resident’s responsible party. Staff #1 further informed LPAs that Resident #1 responsible party was informed by Staff #1 about the concerns of not reporting Resident #1 incidents. Based on the evidence gathered during the investigation, the above allegations are Substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
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 3
Control Number 56-AS-20260706152847
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: 07/07/2026
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 Reporting Requirements 87211 (a)(1)(2), 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 MedTech Desiree Martinez at the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20260706152847
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: 07/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/17/2026
Section Cited
CCR
87211(a)(1)(2)
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Reporting Requirements ...(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case....(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.

This requirement is not met as evidence by:
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The Licensee has agreed to read over regulation: Reporting Requirements(a)(1)(2) and provide training to all staff. Licensee will provide LPA with proof of training by emailing the copy of the training signed and dated by all staff by POC date 7/17/2026.
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Based on record review, interviews, the licensee did not adhere to the regulation stated above by not reporting R#1 incidents to resident’s responsible party, 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.
SUPERVISOR'S NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3