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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530102
Report Date: 04/19/2024
Date Signed: 04/19/2024 10:29:44 AM

Unsubstantiated


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
04/05/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240405124933
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: 91DATE:
04/19/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rebecca ParraTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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9
Staff did not properly address resident's multiple falls resulting in injuries.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Administrator Rebecca Parra and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, Staff did not properly address resident's multiple falls resulting in injuries.
During facility record review LPA found that Resident #1 sustained two falls on 1/16/2024 and on 4/1/2024. Both falls in which Resident #1 received medical treatment. Records also revealed that after Resident #1 last fall the facility updated Resident #1 Needs and Service along with resident’s care plan that addressed the preventative measures that the facility has in place for Resident #1 to prevent continuation of falls. LPA obtained a copy of the facilities current roster and observed that facility has sufficient staffing support to meet resident’s needs.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
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 2
Control Number 56-AS-20240405124933
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: 04/19/2024
NARRATIVE
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 Based on the 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 Rebecca Parra.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2