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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530102
Report Date: 01/22/2025
Date Signed: 01/22/2025 01:49:03 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
09/16/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240916135423
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: 95DATE:
01/22/2025
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:HEATHER O'NEELTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility is not meeting resident care needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator Heather O’Neel and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records.

First allegation: Facility is not meeting resident care needs. Regarding the allegation “Facility is not meeting resident care needs” LPA conducted an interview with Resident #1 Responsible Party who informed LPA that R#1 had developed a bad diaper rash on 9/14/2024. Resident #1 Responsible Party stated to LPA that R#1 had developed a diaper rash because R#1 was left on a soiled diaper for a long period of time. LPA received photograph pictures of R#1 during review of photos LPA observed that R#1 appeared to have a rash and redness around R#1 groin area. Based on the interviews and evidence gathered the above allegation is Substantiated.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
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-20240916135423
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: 01/22/2025
NARRATIVE
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Substantiated: A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, 87411 (a) Personnel Requirements – General, from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along
with a copy of the appeal rights. to Facility Administrator Heather O’Neel.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20240916135423
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: 01/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/29/2025
Section Cited
CCR
87411(a)
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Personnel Requirements – General 87411 (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidence by:
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Administrator has agreed to conduct a training and review Personnel Requirements – General 87411 (a) regulation with all Care Staff. Administrator will provide a copy of completed training signed by all staff and emailed to LPA by POC date 1/29/25.
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Based on observation, interviews, and record review, Licensee did not ensure R#1 basic needs to be met, which poses a potential 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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
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
09/16/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240916135423

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: 95DATE:
01/22/2025
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:HEATHER O'NEELTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Neglect/ lack of supervision resulting in resident to sustain a rib fracture.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility Administrator Heather O'Neel to deliver investigative findings. LPA met with Facility Administrator and explained the purpose of the visit regarding the allegation stated above.

Allegation: Neglect/ lack of supervision resulting in resident to sustain a rib fracture. Investigation conducted by Department staff found that Resident #1 (R1) sustained a fall on 9/1/2024 and R1 denied injuries along with pain. In addition, R1 also denied medical attention and R1 responsible party agreed to R1 medical attention denial. On 09/03/24, R1 sustained a second fall on 9/3/2024, which medical records revealed rib contusion due to an accidental fall, records also denied abuse. Department conducted an interview with R2 who denied neglect/lack of supervision allegation. In addition, Department conducted interviews with Staff #1 and Staff #2 both staff denied neglect and lack of supervision allegation. Due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
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-20240916135423
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: 01/22/2025
NARRATIVE
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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 was discussed, and appeal rights were provided to Facility Administrator Heater O'Neel.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5