LOTUS VILLA AND MEMORY CARE

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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.

Deadline recorded: Jun 15, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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.

Deadline recorded: Jun 15, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87629(a)(b)(1)

Regulation authority

CCR

What the official deficiency says

87629 Injections ....(a) The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional.....(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensees who admit or retain residents who require injections shall be responsible for the following: ....(1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement is not met as evidence by: Based on interviews, the licensee did not adhere by regulation 87629, by permitting a non-skilled professional to administer insulin through injection to resident #4, which poses an immediate health, safety, or personal rights, risk to residents in care.

Official plan of correction

The Licensee has agreed to read over: 87629 Injections (a)(b)(1), regulation and provide training to all staff who assist with the administration of medication. The licensee will ensure that all Medtech’s, Caregivers, have a clear understanding that ONLY appropriately skilled professionals are to administer injections to residents in care. The licensee will email LPA a copy of the signed training and acknowledged by all Med-Support by POC 4/14/2026.

Deadline recorded: Apr 14, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities General....(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:....(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on interviews, and record review, the licensee did not ensure R#1 to be accorded safe, based on title 22 regulation, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Licensee has agreed to read over the " Personal Rights General " and provide training to all staff regarding care and supervision. The licensee will email a copy of the training on POC date 10/3/2025.

Deadline recorded: Oct 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (a) ....A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:.....(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidence by: Based on observation, interviews, and record review, the licensee did not ensure to follow " Incidental Medical and Dental Care " for R#1 who did not receive medication on time, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Licensee has agreed to read over the Incidental Medical and Dental Care(a)(2) and provide training on medication management along with the storing of medication. Training will be emailed and provided to LPA Guerrero by POC date 8/29/2025.

Deadline recorded: Aug 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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.

Deadline recorded: Jan 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with personal accommodations and by blocking interior emergency door exits with a dining room chair and a reclining chair; in, addition LPA observed a master lock on exterior exit gate which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/30/2023 Plan of Correction Facility Operation Manager Cleared POC during inspection. Removed lock; removed chairs from emegency exits.

Official classification

Type A

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

(g) All personnel records shall be maintained at the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with personnel Records 1 out 5 Caregivers missing CPR trainings in personnel record which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/31/2023 Plan of Correction S#1 cannot provide care to residents without completing CPR training. Administrator will submitt documented proof indicating that S#1 has been enrolled on CPR training by POC date 8/31/23. In addition, Administrator will submit proof of training once training has been completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section maintenance and operation; x2 lights in dinning room #1 not working; x1 lights not wokring in dining room #2. Second floor outside room #214 partially collapsing. X2 broken windows on 2nd floor. Hallway light missing cover. Second floor entry door to staff break room had battery exposed on auditory device which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2023 Plan of Correction Administrator will provide invoices, from a licensed contractor noting when the repairs will be taking place. Administrator will also cone off and post caution signage do not enter area below roof for safety precautions to residents. Administrator will provide pictures of signage in danger area. POC will emailed to assigned LPA on POC date 9/29/23.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, the lincensee did not comply with the section maintenance and operation; Water temperature in rooms are below temperature, lowest reading 85.1 F highest 96.6 F. Main restroom near dining room#1 hot water not working temperature reading was at 76.5 F and dining room #2 sink was broken (No hot running water) not allowing LPA to measure water temperature which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2023 Plan of Correction Administrator will provide invoices, noting maintenance repairs for bellow hot water temperature and sink repair in kitchen room on second floor. With no water running on hot side of the sink. Administrator will provide proof of maintenance repairs to assigned LPA on POC date 9/29/23.

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the storage pace section. Laundry Room on assisted living side was unlocked, unsercure bleach was left in laundry room, maintanence room was unlocked, exposed chemical (fabuloso) was left unsecure. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2023 Plan of Correction Licensee shall provide training on how to properly main toxic chemicals secured when chemicals not being utilzed. Licensee will provided ackowledgement and signed training on how to manage and secure toxic chemicals by POC date 9/29/2023

Official classification

Type B

Official code

87355(j)

Regulation authority

CCR

What the official deficiency says

(j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file as required in Section 87412, Personnel Records. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above; caregivers are associated to facility and cleared however, criminal record clearance is not in personnel records.which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/30/2023 Plan of Correction Administrator printed criminal record clearance from guardian for S#2, S#3, and S#4. Administrator agreed to keep the required documentation on file for all personnel records going forward. POC was cleared during visit

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section Care of Persons with Dementia; By not having auditory devices on windows which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/31/2023 Plan of Correction Administrator shall provide CCL department a plan of implementing audio devices on every window in the dementia care unit. Plan shall be completed by POC date 8/31/23.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section fire safety; total of six non-auto closing fire doors were propted open with door stoppers, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/31/2023 Plan of Correction During the visit administrator closed all six non- auto closing fire doors. Administrator will send LPA fire safety training regarding non-auto closing doors as acknowlegement.