Lotus Villa And Memory Care

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

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 Actthe state’s words, verbatim · CDSS document, Jun 12, 2026 · control 56-AS-20250911105509

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Unqualified staff provide medical care to residents.

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: Unqualified staff provide medical care to residents. Regarding the allegation stated above, LPAs conducted interviews with Resident #1, Resident #2, Resident #3, and Resident #4, pertaining to the alleged allegation and three out of the four residents informed LPAs that they independently administer their own insulin as well as checking their own blood sugar. During further interview Resident #4 informed LPA that facility staff assists with the administration of insulin. Resident #4 further explained that the assistance is not hand over hand assistance but full injectable administration of insulin. Resident #4 also stated that the last administration done by staff was about a week ago. Based on the evidence gathered during the investigatithe state’s words, verbatim · CDSS document, Apr 13, 2026 · control 56-AS-20260304110227

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff unlawfully evicted a resident

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator Melisa Sevilla and explained the purpose of the visit. The investigation consisted of interviews, review of records, and observations. First allegation: Staff unlawfully evicted a resident. Regarding the allegation LPA conducted interviews with Staff #1, Staff #2, and Staff #3, LPA went over the allegation with staff and S#1-3 informed LPA that the facility has not evicted or refuse to accept any resident back the facility. Based on records LPA observed that no name of the victim was listed or provided for the unlawful eviction. Staff #3 informed LPA that one resident, Resident #1 was transported to a local hospital on 10/22/2023 and discharged on 10/23/2025 Staff #3 informed LPA that facility was having arrangement issues pertaining to R#1 however, Staff #3 informed LPA that R#1 was later transported to back the facilitythe state’s words, verbatim · CDSS document, Oct 27, 2025 · control 56-AS-20251023100251

Allegation investigated: Facility staff are not properly addressing bed bugs in the facility

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator Melisa Sevilla and explained the purpose of the visit. The investigation consisted of interviews, review of records, and observations. First allegation: Facility staff are not properly addressing bed bugs in the facility. Regarding the allegation, LPA conducted interviews with Staff #1, Staff #2, and Staff #3, who informed LPA that the facility received a report from a resident on 10/7/2025 regarding bedbugs. Based on treatment contract LPA observed that a two-day treatment was completed on 10/13 and on 10/24/2025, staff informed LPA that treatment has been completed, and the indication of bedbugs was no longer present. In addition, Staff informed LPA that a total of four (4) residents will be moving back into their rooms in the next couple of days. LPA conducted interviews with R#2, R#3, and R#4, who informed LPA that ththe state’s words, verbatim · CDSS document, Oct 27, 2025 · control 56-AS-20251020101251

Allegation investigated: Staff do not provide adequate supervision to the residents in care.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Business Office Manager Reyna Figueroa and explained the purpose of the visit. The investigation consisted of interviews, and review of records. First allegation: Staff do not provide adequate supervision to the residents in care. Regarding the allegation LPA conducted interviews with staff #1 and staff #2 who informed LPA that on 9/19/2025, it was reported by staff that R#1 had not been seen and was possibly missing. S#1 and S#2 informed LPA that family and local police department were notified of the incident pertaining to R#1. S#1 informed LPA that R#1 was found three in a half hours later (3.5 hrs.) and was found to be inside a storage room located on the second-floor same floor where R#1 room is located. S#1 informed LPA that storage room was accidently left opened which R#1 gained access and was locked in the storage room for 3.5the state’s words, verbatim · CDSS document, Sep 22, 2025 · control 56-AS-20250915144012

Allegation investigated: Staff did not follow up on resident's change of condition Staff left resident in filthy clothes Staff did not ensure resident in care was hydrated Staff did not ensure resident in care was properly fed Staff did not provide proper medication assistance to resident in care

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, observation, and review of records. First allegation: Staff did not follow up on resident's change of condition. Regarding the allegation stated above LPA conducted interviews with S#1, S#2, and S#3, who informed LPA that on 11/19/2023, facility informed InnoVage clinic that Resident #1 was being transported to local hospital because R#1 was weak and was not eating. LPA collected documentation pertaining to R#1 and LPA discovered that on 11/19/2023, R#1 was seen at a local hospital and diagnosed with UTI R#1, was discharged on the same day. LPA observed that medication was set to be delivered to the facility per InnoVage orders. LPA observed that R#1 completed antibiotics as indicated in addition, based on R#1 follow-up inforthe state’s words, verbatim · CDSS document, Aug 26, 2025 · control 56-AS-20231215091035

Allegation investigated: Facility staff are not administering residents’ insulin as prescribed.

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 staff are not administering residents’ insulin as prescribed. Regarding the allegation LPA conducted interviews with Staff #1 and Staff #2, provided LPA with a verbal admission, that R#1 did not receive insulin medication because R#1 insulin could not be located. S#1 and S#2 informed LPA that R#1 insulin medication was later located and found to be inside Med-room refrigerator. Because R#1 insulin was not located and found several days later R#1 was not able to receive their medication as prescribed. Based on the evidence gathered during the investigation, the above allegation is Substantiated. Substantiatedthe state’s words, verbatim · CDSS document, Aug 20, 2025 · control 56-AS-20240416172928

Allegation investigated: Staff allowed resident to become dehydrated while in care. Staff did not prevent outbreak of covid. Staff did not report a change in resident's condition to resident's responsible party. Staff did not provide adequate care to resident while in care.

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: Staff allowed resident to become dehydrated while in care. Regarding the allegation LPA conducted interviews with Resident #2-5 regarding the allegation listed above all residents informed LPA that facility has water available to all residents. In addition, resident #2-5, informed LPA that facility has water dispensers available throughout the facility, and that water is also provided upon residents’ request. LPA conducted interviews with Staff #1-5, regarding the allegation stated above, and staff #1-5 informed LPA that there is a total of three (3), water stations available to residents and that water is also available upon residents’ request. Furthermore, staff #1-5 althe state’s words, verbatim · CDSS document, Aug 11, 2025 · control 56-AS-20240830134517

Allegation investigated: Staff did not safeguard resident's personal item. Staff did not prevent a resident from sustaining falls while in care. Staff did not prevent residents from engaging in an altercation. Staff did not respond to resident's call light.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Business Office Manager Reyna Figueroa and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records. First allegation: Staff did not safeguard resident's personal item. Regarding the allegation LPA conducted an interview with Resident#1 pertaining to the allegation R#1 informed LPA that resident does not know if resident’s cellphone was misplaced, lost, or stolen. Resident #1 informed LPA that resident shares a room, however, resident#1 does not know if roommate or staff might have taken R#1 cellphone as R#1 has not witnessed any theft. Resident #1 informed LPA that resident has a designated area where resident stores their personal items. LPA conducted a review of R#1 records during the review of records LPA observed an inventory sheet that lists all valuable items pertaining tthe state’s words, verbatim · CDSS document, Jul 24, 2025 · control 56-AS-20250418130652

Allegation investigated: Staff neglect resulted in resident falling. Staff did not ensure resident’s room was adequately cleaned. Staff did not ensure resident’s room was free from odors. Staff did not safeguard resident's personal belongings. Staff did not assist resident with personal hygiene care.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Business Office Manager Reyna Figueroa and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records. First allegation: Staff neglect resulted in resident falling. Regarding the allegation listed above LPA conducted a review of records pertaining to Resident #1 during the review of records LPA discovered that R#1 sustained an unwitnessed fall on 9/25/2024, based on report R#1 was later transported to local hospital for treatment. During further investigation LPA observed that R#1 has not sustained no falls since initial fall that occurred on 9/24/2024. LPA conducted an interview with Resident#1 pertaining the allegation stated above R#1 informed LPA that during the fall resident was attempting to lean to the side and went a little to far and that is when resident sustained the fathe state’s words, verbatim · CDSS document, Jul 22, 2025 · control 56-AS-20250210141739

Allegation investigated: Licensee is financially abusing resident(s) in care. Staff do not respond to residents' requests for assistance as necessary. Staff do not accord dignity to resident(s) in care.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Business Office Manager Reyna Figueroa and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records. First allegation: Licensee is financially abusing resident(s) in care. Regarding the allegation stated above LPA conducted an interview with Business Office Manager who informed LPA all rent payments are received and processed by facility Business Office Manager (BOM). Business Office Manager informed LPA that all residents receive a proof of payment and upon request. In addition, BOM explained to LPA that all residents receiving SSI at the end of the year receive a 2.5-percent cost of living increase deemed by social security. BOM further explained that due to the cost-of-living increase residents rents get impacted (increased). LPA conducted interviews with four residents and four out othe state’s words, verbatim · CDSS document, Jun 6, 2025 · control 56-AS-20250213100958

Allegation investigated: Resident sustained multiple falls due to lack of supervision.

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: Resident sustained multiple falls due to lack of supervision. Regarding the allegation listed above LPA collected documentation pertaining to R#1. During the review or R#1 documentation LPA discovered that R#1 was able to ambulate via walker, and facility caregivers will assist as needed. On 7/12/2024, and 7/13/2024, R#1 sustained two unwitnessed falls in which paramedics were notified and transferred R#1 to be treated. Based on R#1 needs, and service plan R#1 was receiving escorting as needed as well as observation checks every two hours. LPA conducted interview with R#2 who denied pushing R#1 or being aggressive towards any other residents. R#2 reported not witnessing Rthe state’s words, verbatim · CDSS document, Feb 7, 2025 · control 56-AS-20240716144230

Allegation investigated: Facility is not meeting resident care needs

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. Substantiatedthe state’s words, verbatim · CDSS document, Jan 22, 2025 · control 56-AS-20240916135423

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: 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 .

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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 20, 2024 · control 56-AS-20240610140357

Allegation investigated: Staff did not treat resident with respect. Staff slapped resident.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations 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 treat resident with respect. During the course of the investigation, interviews were conducted, a review of resident (R1) records was completed and copy of pertinent documents were obtained. Regarding the alleged allegation, staff did not treat resident with respect. interviews with staff were conducted and all staff denied mistreating resident[s] or violating resident[s] rights in addition, staff also denied witnessing staff mistreat or violate resident[s] rights. Interviews with residents were conducted where 4 out five residents denied being mistreated or their personal rights to be violated by staff. In addition, four residents denied witnessing staff mistreating or viothe state’s words, verbatim · CDSS document, Jun 20, 2024 · control 56-AS-20240416115905

Allegation investigated: Staff did not properly address resident's multiple falls resulting in injuries.

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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 19, 2024 · control 56-AS-20240405124933

Allegation investigated: Staff serve food that is of poor quality.

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 serve food that is of poor quality. LPA observed and inspected the quantity and quality of food on (2) separate facility visits. LPA conducted interviews with kitchen staff. LPA conducted a review of food service of meals served. LPA collected a copy of the current menu, along with the alternative menu. LPA collected a copy of the internal food temperature logs and food handlers training certificates. LPA toured the facility and observed the meals that are being served reflected on what was on the menu for the week. LPA observed food to be of adequate quality. Meals appeared to be fresh and balanced. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 19, 2024 · control 56-AS-20240325145341

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.