365530102-9-20-2024-56-AS-EMAN-DB7T6Y-20241120132755

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 365530102
Report Date: 09/20/2024
Date Signed: 09/20/2024 01:39:14 PM

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
06/10/2024 and conducted by Evaluator Paola Guerrero

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20240610140357

FACILITY NAME:	LOTUS VILLA AND MEMORY CARE		FACILITY NUMBER:	365530102
ADMINISTRATOR:	PARRA, REBECCA		FACILITY TYPE:	740
ADDRESS:	9448 CITRUS AVENUE		TELEPHONE:	(909) 355-6887
CITY:	FONTANA	STATE: CA	ZIP CODE:	92335
CAPACITY:	99	CENSUS: 94	DATE:	09/20/2024
		UNANNOUNCED	TIME BEGAN:	12:39 PM
MET WITH:	Reyna Figueroa		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff do not ensure resident records are properly maintained.
Facility does not ensure staff follow infection control requirements.
Staff do not ensure residents medications are properly stored and secured .

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Paola Guerrero and Beena Singh conducted an unannounced visit to deliver findings on the allegations listed above. LPAs met with Administrative Assistant Reyna Figueroa and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, Staff do not ensure resident records are properly maintained. Regarding the allegation “Staff do not ensure residents records are properly maintained” LPA Guerrero conducted a record inspection in facilities Med-room LPA observed med-room to be locked. Med-room was opened by Staff #1. LPA observed that all Residents records were filed in a secured and designated area. LPA inspected MAR record along with residents’ medication card and observed medication to be dispensed and recorded properly by staff.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20240610140357

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: 09/20/2024

NARRATIVE

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Second allegation, Facility does not ensure staff follow infection control requirements. Regarding the allegation “Facility does not ensure staff follow infection control requirements” LPA conducted interviews and review of records based on review of records LPA discovered that facility does not have any current incident reports regarding scabies. LPA observed facility to have an infection control plan in place on how to properly asses’ contagious outbreaks or cases such as scabies. Facility Administrator informed LPA that facility currently does not have anyone being treated or exposed to scabies.

Third allegation, Staff do not ensure residents medications are properly stored and secured. Regarding the allegation “Staff do not ensure residents medications are properly stored and secured” LPA conducted a medication inspection in facilities Med-room office LPA observed med-room to be locked and opened by Staff #1. During med inspection LPA asked Staff #1 to unlock med cart, LPA observed residents’ medication to be locked and secured in med cart. In addition, LPA observed PRN medication to be locked and secured in med cart. LPA inspected MAR record along with residents’ medication cards and observed medication to be dispensed and recorded properly by staff. 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 Administrative Assistant Reyna Figueroa at the end of the visit.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC9099 (FAS) - (06/04)

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