365530102-6-12-2026-56-AS-EMAN-DVBUAX-20260623152528

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 365530102
Report Date: 06/12/2026
Date Signed: 06/12/2026 05:42:55 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
09/11/2025 and conducted by Evaluator Paola Guerrero

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20250911105509

FACILITY NAME:	LOTUS VILLA AND MEMORY CARE		FACILITY NUMBER:	365530102
ADMINISTRATOR:	HEATHER O'NEEL		FACILITY TYPE:	740
ADDRESS:	9448 CITRUS AVENUE		TELEPHONE:	(909) 355-6887
CITY:	FONTANA	STATE: CA	ZIP CODE:	92335
CAPACITY:	99	CENSUS: 94	DATE:	06/12/2026
		UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Mayra Alfaro		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Staff neglect resulted in resident being hospitalized.
Facility staff did not meet the residents’ care needs.

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: Staff neglect resulted in R1 being hospitalized.
Investigation was conducted by department staff which included review of records and witness interviews. Based on the investigation, it was discovered that facility staff observed a significant decline in Resident #1 (R1)’s condition but staff continued to let critical time pass while R1’s condition continued to decline throughout August 2025.

An appraisal dated March 28, 2024, and a preplacement appraisal dated April 15, 2024, show R1’s overall health as being good. In addition, a physician’s report dated May 2, 2025 indicated R1’s health as fair. In addition, a Needs and Service plan dated August 6, 2025, indicates that R1 was able to make their needs known and needing assistance with Activities of Daily Living (ADLs).

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026

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 4

Control Number 56-AS-20250911105509

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: 06/12/2026

NARRATIVE

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Documentation dated July 26, 2025, shows R1 had a decrease in eating and drinking over the last two days and needing extra encouragement to eat. On July 28, documentation shows that R1 health was declining, eating and drinking had diminished and R1 sometimes refused eating with increased weakness and fatigue. Records show that on July 31, 2025, R1 was determined to be appropriate to receive hospice services. However, hospice was not initiated. The Operations Manager acknowledged that R1 was not eating or drinking for some time in August so Boost shakes were ordered. However, there was no documentation to confirm fluid intake or when Boost shakes were provided. In addition, there was no documentation showing that staff assisted R1 with eating or drinking or assistance with spoon-feeding due to weakness. R1 was hospitalized on September 1, 2025, and medical records show R1 had a gradual decline and failure to thrive since August 28, 2025. A nutrition assessment dated September 3, 2025, charts significant unintentional weight loss of 27% over the last three months. R1 was determined to be severely malnourished. Her weight was 150lbs on April 19, 2025, and 110 on September 2, 2025. R1 was hospitalized on September 1 and diagnosed with severe sepsis, pneumonia, dehydration and malnutrition. R1 died in the hospital on September 8, 2025.

Second allegation: Facility staff did not meet the residents’ care needs.
Regarding the second allegation, it was Investigated through department staff that throughout R#1 stay at Lotus Villa R#1 was hospitalized three (3) times, March 2025, April 19, 25, and June 9, 2025. None of the hospitalizations were reported to resident responsible party by staff. It was reported that resident responsible party learned about the hospitalizations when called directly by Kaiser Permanente. Report indicates that prior to R#1 hospitalization on September 1, 2025, R1 lost a significate amount of weight. In addition, staff did not assist R#1 with Activities of Daily Living (ADL’s), but rather left R1 in bed, not being assisted with feeding or grooming. Report also indicated that staff did not administer oxygen to R#1 for over a month. Records indicate that upon R#1 hospitalization to Kaiser Permanente on September 1, R#1 was found to be severely septic with pneumonia, dehydrated, and malnourished.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 56-AS-20250911105509

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: 06/12/2026

NARRATIVE

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Based on the evidence gathered during the investigation the allegation of neglect and facility did not meet the residents care needs are substantiated. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence standard has been met. In addition, an immediate civil penalty of $500.00 was assessed, per Health and Safety Code 1548 (c). Furthermore, an additional civil penalty may be imposed, per Health and Safety Code 1569.49 (f).

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: 06/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 56-AS-20250911105509

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: 06/12/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/15/2026 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Residents: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidence by:	1 2 3 4 5 6 7	The Licensee has agreed to read over regulation 87466 Observation of the Residents: and provide training to all staff who provide care to residents. The licensee will also provide LPA with proof of the training signed by all participating staff acknowledging and understanding the regulation by POC date: 6/15/2026.
	8 9 10 11 12 13 14	Based on, interviews and record review, the licensee did not adhere or follow protocol based on the regulation listed above which resulted in R#1 being hospitalized on 9/1/2025, and diagnosed with severe sepsis, pneumonia, dehydration and malnutrition. This posed an immediate Health, Safety, or Personal Rights risk to residents in care.	8 9 10 11 12 13 14
Type A 06/15/2026 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	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. This requirement is not met as evidence by:	1 2 3 4 5 6 7
	8 9 10 11 12 13 14	Based on, interviews and record review, the licensee did not adhere to the regulation stated above by not properly reporting R#1 change of condition and not adhering to R#1 care needs which resulted in R#1 to be hospitalized on 9/1/2025, and diagnosed with severe sepsis, pneumonia, dehydration and malnutrition. This posed an immediate Health, Safety, or Personal Rights risk to residents in care.	8 9 10 11 12 13 14	The Licensee has agreed to read over regulation 87411 (a) Personnel Requirements – General: and provide training to all staff who provide care to residents. The licensee will also provide LPA with proof the of the training signed by all participating staff acknowledging and understanding the regulation by POC date: 6/15/2026.

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: 06/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026

LIC9099 (FAS) - (06/04)

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