Inspection Report Summary
Most inspections at Lotus Villa and Memory Care Facility found no deficiencies, with several complaint investigations resulting in unsubstantiated allegations related to resident care, hygiene, and facility conditions. However, some reports did identify isolated issues, including a substantiated failure to administer insulin as prescribed in August 2025 and insufficient staffing leading to unmet resident care needs in January 2025. The most recent report from August 26, 2025, was clean with no deficiencies and found all complaint allegations unsubstantiated. Earlier licensing inspections in 2023 revealed multiple environmental safety and personnel record deficiencies, but these issues do not appear in more recent reports. Overall, the facility’s record shows improvement over time, with the latest investigations indicating compliance with care standards and no serious enforcement actions or fines listed.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% better than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
95% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 94
Capacity: 99
Deficiencies: 0
Date: Aug 26, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 12/15/2023 regarding resident care concerns at Lotus Villa and Memory Care Facility.
Complaint Details
The complaint investigation was triggered by allegations that staff did not follow up on a resident's change of condition, left a resident in filthy clothes, failed to ensure hydration and proper feeding, and did not provide proper medication assistance. The investigation found no preponderance of evidence to substantiate these allegations.
Findings
The investigation included interviews, observations, and record reviews related to allegations of inadequate follow-up on resident condition changes, poor hygiene, hydration, feeding, and medication assistance. The findings determined all allegations to be unsubstantiated based on evidence and interviews.
Report Facts
Capacity: 99
Census: 94
Medication duration: 5
Water stations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paola Guerrero | Licensing Program Analyst | Conducted the complaint investigation |
| Efren Malagon | Licensing Program Manager | Oversaw the complaint investigation |
| Heather O'Neel | Facility Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 99
Deficiencies: 1
Date: Aug 20, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-04-16 alleging multiple issues including failure to administer insulin as prescribed, resident injury, lack of phone access, inadequate cleaning, facility disrepair, and failure to follow diabetic diet.
Complaint Details
The complaint investigation was substantiated for the allegation that facility staff failed to administer insulin medication as prescribed to resident #1 because the insulin was misplaced in the medication room refrigerator and not given on time. Other allegations including resident injury, phone access, bathroom cleanliness, facility disrepair, and diabetic diet noncompliance were unsubstantiated.
Findings
The investigation substantiated the allegation that facility staff did not administer insulin as prescribed to a resident due to medication being misplaced. Other allegations including resident injury, phone access, bathroom cleaning, facility disrepair, and diabetic diet were found unsubstantiated based on interviews, observations, and record reviews.
Deficiencies (1)
Licensee did not ensure to follow 'Incidental Medical and Dental Care' for a resident who did not receive medication on time, posing an immediate health, safety, or personal rights risk.
Report Facts
Capacity: 99
Census: 94
Deficiencies cited: 1
Plan of Correction Due Date: Aug 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paola Guerrero | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Heather O'Neel | Facility Administrator | Met with Licensing Program Analyst during investigation and discussed findings |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 99
Deficiencies: 0
Date: Aug 11, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-08-30 regarding dehydration, COVID outbreak prevention, reporting of resident condition changes, and adequacy of care at the facility.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred. Allegations included dehydration, failure to prevent COVID outbreak, failure to report resident condition changes, and inadequate care, all of which were found unsubstantiated after investigation.
Findings
The investigation, which included interviews, observations, and record reviews, found all allegations to be unsubstantiated based on corroborating evidence and resident and staff interviews indicating appropriate care and procedures were followed.
Report Facts
Capacity: 99
Census: 94
Number of water stations: 3
Number of allegations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paola Guerrero | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Heather O'Neel | Facility Administrator | Met with Licensing Program Analyst during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 99
Deficiencies: 0
Date: Jul 24, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2025-04-18 regarding staff safeguarding resident's personal items, preventing falls, preventing altercations, and responding to call lights.
Complaint Details
The complaint involved four allegations: staff did not safeguard resident's personal item, did not prevent falls, did not prevent altercations, and did not respond timely to call lights. After investigation, all allegations were found unsubstantiated.
Findings
The investigation included interviews, observations, and record reviews. All allegations were determined to be unsubstantiated due to lack of preponderance of evidence. The facility had programs and procedures in place related to the allegations, and residents and staff provided explanations consistent with the findings.
Report Facts
Facility capacity: 99
Census: 91
Fall risk check interval: 15
Fall risk check interval: 30
Resident fall date: Jun 11, 2025
Call light response time: 30
Call light response time: 35
Call light wait time: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paola Guerrero | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Efren Malagon | Licensing Program Manager | Oversaw the complaint investigation |
| Heather O'Neel | Administrator | Facility administrator named in the report |
| Reyna Figueroa | Facility Business Office Manager | Met with Licensing Program Analyst during investigation |
| Desiree Martinez | Med-Tech | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 99
Deficiencies: 0
Date: Jul 22, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2025-02-10 regarding multiple allegations of staff neglect and inadequate care at the facility.
Complaint Details
The complaint included allegations of staff neglect resulting in a resident fall, inadequate cleaning and odor control in a resident's room, failure to safeguard personal belongings, and lack of assistance with personal hygiene care. The investigation found no evidence to substantiate these allegations.
Findings
The investigation included interviews, observations, and record reviews related to five allegations. All allegations were found to be unsubstantiated based on evidence and interviews with the resident and staff.
Report Facts
Facility capacity: 99
Census: 92
Date complaint received: Feb 10, 2025
Resident fall date: Sep 25, 2024
Resident shower schedule: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paola Guerrero | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Reyna Figueroa | Facility Business Office Manager | Met with Licensing Program Analyst during the investigation and received the report |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 99
Deficiencies: 0
Date: Jun 6, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2025-02-13 regarding financial abuse of residents, staff not responding to residents' requests for assistance, and staff not according dignity to residents.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred. Allegations included financial abuse, lack of staff response to assistance requests, and lack of dignity accorded to residents.
Findings
The investigation, which included interviews with residents, staff, and review of records, found no evidence to substantiate the allegations. Residents and staff denied the claims, and the Licensing Program Analyst determined the allegations to be unsubstantiated.
Report Facts
Capacity: 99
Census: 97
Complaint control number: 56-AS-20250213100958
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paola Guerrero | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Reyna Figueroa | Business Office Manager | Interviewed during investigation and met during visit |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 99
Deficiencies: 0
Date: Feb 7, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-07-16 alleging that a resident sustained multiple falls due to lack of supervision.
Complaint Details
The complaint alleged that a resident sustained multiple falls due to lack of supervision. The investigation found no evidence to substantiate the allegation. The allegation was deemed unsubstantiated.
Findings
The investigation included interviews, observations, and record reviews. The Licensing Program Analyst found that the resident was ambulatory with assistance and received escorting and observation checks as needed. Interviews with residents and staff did not corroborate the allegation of lack of supervision or mistreatment. The allegation was determined to be unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 99
Census: 95
Complaint received date: Jul 16, 2024
Incident dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paola Guerrero | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Heather O'Neel | Administrator | Facility Administrator met during the investigation and exit interview |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 99
Deficiencies: 1
Date: Jan 22, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2024-09-16 alleging that the facility was not meeting resident care needs and neglect/lack of supervision resulting in a resident sustaining a rib fracture.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility failed to meet resident care needs, evidenced by a resident developing a diaper rash from being left on a soiled diaper. The allegation of neglect and lack of supervision causing a rib fracture was unsubstantiated after interviews and record reviews.
Findings
The investigation substantiated the allegation that the facility did not meet resident care needs, specifically related to a resident developing a diaper rash due to being left on a soiled diaper for a prolonged period. The allegation of neglect/lack of supervision resulting in a rib fracture was unsubstantiated due to insufficient evidence.
Deficiencies (1)
Personnel Requirements – General 87411 (a): Facility personnel were not sufficient in numbers and competence to meet resident needs, resulting in failure to ensure Resident #1's basic needs were met.
Report Facts
Capacity: 99
Census: 95
Deficiency count: 1
Plan of Correction Due Date: Jan 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paola Guerrero | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Efren Malagon | Licensing Program Manager | Oversaw the complaint investigation |
| Heather O'Neel | Facility Administrator | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Annual Inspection
Census: 93
Capacity: 99
Deficiencies: 0
Date: Nov 6, 2024
Visit Reason
The visit was an unannounced required comprehensive annual inspection of the Residential Care Facility for Elderly (RCFE).
Findings
The facility was found to be operating within approved capacity and in good repair with no obstructions or safety hazards. Resident rooms and common areas were adequately furnished and maintained. Medications were properly stored and dispensed. Staff had required clearances and certifications. No deficiencies were cited during this inspection.
Report Facts
Resident files reviewed: 6
Staff files reviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather O'neel | Facility Administrator | Met with Licensing Program Analysts during inspection and exit interview |
| Paola Guerrero | Licensing Program Analyst | Conducted the inspection and signed the report |
| Beena Singh | Licensing Program Analyst | Conducted the inspection |
| Efren Malagon | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 99
Deficiencies: 0
Date: Sep 20, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations received on 06/10/2024 regarding resident records maintenance, infection control, and medication storage and security.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found that resident records were properly maintained and secured, infection control requirements were followed with no current incidents of scabies, and residents' medications were properly stored and secured. All allegations were determined to be unsubstantiated due to lack of evidence.
Report Facts
Capacity: 99
Census: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paola Guerrero | Licensing Program Analyst | Conducted the complaint investigation |
| Efren Malagon | Licensing Program Manager | Named in report as Licensing Program Manager |
| Reyna Figueroa | Administrative Assistant | Met with investigators during the visit |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 99
Deficiencies: 0
Date: Jun 20, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-04-16 regarding staff mistreatment and physical assault of residents.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff did not treat resident with respect and staff slapped resident. Interviews with staff and residents did not support the allegations, and no evidence was found to prove the violations occurred.
Findings
The investigation included interviews with staff and residents and review of records. All allegations, including staff not treating residents with respect and staff slapping a resident, were found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 99
Census: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paola Guerrero | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Rebecca Parra | Facility Administrator | Met with Licensing Program Analyst during the investigation and received the report |
| Efren Malagon | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 99
Deficiencies: 0
Date: Apr 19, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not properly address a resident's multiple falls resulting in injuries.
Complaint Details
The complaint alleged that staff did not properly address a resident's multiple falls resulting in injuries. The allegation was found unsubstantiated after investigation.
Findings
The investigation found that Resident #1 sustained two falls requiring medical treatment. The facility updated the resident's care plan to address fall prevention and has sufficient staffing to meet resident needs. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 99
Census: 91
Resident falls: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paola Guerrero | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Rebecca Parra | Facility Administrator | Met with Licensing Program Analyst during investigation |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 99
Deficiencies: 0
Date: Apr 19, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2024-03-25 alleging that staff serve food of poor quality.
Complaint Details
The complaint alleging poor quality food was investigated and found to be unsubstantiated.
Findings
The Licensing Program Analyst conducted interviews, reviewed records, and observed meals during two separate visits. The investigation found that food served was of adequate quality, fresh, balanced, and consistent with the menu. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 99
Census: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paola Guerrero | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Rebecca Parra | Facility Administrator | Met with Licensing Program Analyst during the investigation |
| Efren Malagon | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Original Licensing
Census: 80
Capacity: 99
Deficiencies: 0
Date: Nov 15, 2023
Visit Reason
An announced pre-licensing visit was conducted to evaluate the facility for a Residential Care Facility for Elderly (RCFE) license with a capacity of 99 residents.
Findings
The facility was found to be in good repair with no hazards, all resident bedrooms and bathrooms adequately furnished and maintained, safety equipment functional, and emergency plans posted. No corrections were needed following the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eli Goldman | Operations Manager | Met with Licensing Program Analyst during the pre-licensing visit and accompanied the tour of the facility. |
Inspection Report
Original Licensing
Census: 70
Capacity: 99
Deficiencies: 8
Date: Aug 30, 2023
Visit Reason
An announced pre-licensing visit was conducted to evaluate the facility's readiness for licensing as a Residential Care Facility for Elderly (RCFE) with 93 non-ambulatory and 6 bedridden beds.
Findings
The inspection identified multiple deficiencies including environmental safety issues such as non-working lights, broken windows, blocked emergency exits, unsecured chemicals, and fire safety concerns with propped open fire doors. Personnel records were incomplete with missing CPR training and absent criminal record clearances. Water temperatures were below required levels and auditory devices were missing in the dementia care unit.
Deficiencies (8)
Blocked interior emergency door exits with a dining room chair and a reclining chair; master lock on exterior exit gate posing immediate risk.
One out of five caregivers missing CPR training in personnel records.
Two lights in dining room #1 and one light in dining room #2 not working; second floor outside room #214 partially collapsing; two broken windows on second floor; hallway light missing cover; exposed battery on auditory device at staff break room door.
Water temperature in resident rooms below required minimum; hot water not working in main restroom near dining room #1 and broken sink in dining room #2.
Laundry room unlocked with unsecured bleach; maintenance room unlocked with unsecured chemical (Fabuloso).
Criminal record clearance documentation missing from personnel records for caregivers.
Dementia care unit lacks auditory devices on windows to monitor exits.
Six non-auto closing fire doors were propped open with door stoppers.
Report Facts
Deficiencies issued: 8
Caregivers missing CPR training: 1
Fire doors propped open: 6
Facility capacity: 99
Census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eli Goldman | Facility Operation Manager | Met with LPAs during inspection and involved in correction of deficiencies. |
| Rebecca Parra | Administrator | Named in relation to personnel training and plans of correction. |
Inspection Report
Original Licensing
Census: 99
Capacity: 99
Deficiencies: 0
Date: Jun 13, 2023
Visit Reason
The visit was conducted as part of the original licensing process (CHOW application) for Lotus Villa and Memory Care facility to verify compliance with community care facility licensing laws and readiness for operation.
Findings
The applicant and administrator participated in a telephone interview (COMP II) confirming their understanding of licensing laws, facility operation, admission policies, staffing requirements, emergency preparedness, complaints reporting, and pre-licensing readiness. Identification was verified and required documentation obtained.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Parra | Administrator | Administrator participating in licensing interview and verification |
| Ezequiel Bercovich | Licensee | Licensee participating in licensing interview and verification |
| Eli Goldman | Supervisor | Supervisor participating in licensing interview and verification |
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