Neglectful, unprofessional, unreliable dementia care
I placed my father here; the facility is bright and modern, the rooms pleasant and some caregivers were friendly with good food, but overall the standard of care was poor and unreliable. We saw missed meds and pain relief, residents left in urine for hours, lack of basic supplies (towels, linens, diapers), limited showers, no diabetic meals, overflowing trash, and multiple missing personal items. Administration was unprofessional and retaliatory-blaming CNAs, threatening eviction, emailing/venting to families-and a county investigation substantiated prior neglect. A new manager (Jennifer) appears more professional, but dementia supervision, activities, compassion, and accountability are still lacking; I cannot recommend this place.
Lotus Villa And Memory Care stands on Citrus Avenue in Fontana, California, and is a licensed senior living facility with care for up to 99 residents. Administrator Becky oversees the Memory Care unit, where staff watch over residents who have memory problems, dementia, or Alzheimer's. The community focuses on keeping residents safe with a secure setting that's clean and well organized, and caregivers are known for being helpful and attentive. Residents can get both Assisted Living and Memory Care services, with personalized help for daily health checks, medication, incontinence, and high-needs care, and staff speak English, Spanish, and Filipino to help with communication. Meals for residents are prepared with care, and there are special options like kosher, vegan, vegetarian, low sodium, and no sugar meals, and friends and family are welcome to join residents at the large dining hall when they visit, which is good for gathering on special occasions.
The accommodations include spacious private rooms and 1-bedroom, 1-bath studios, each with air conditioning, cable or satellite TV, Wi-Fi, wheelchair accessible showers, and room service or guest meals available. Residents have spaces where they can relax, like a library, a landscaped outdoor area for picnics with family, a laundry room, and a conference room that's set aside for private conversations. There are indoor common areas so families can visit in comfort while waiting for their loved ones, and all rooms are handicap accessible. The facility doesn't allow pets, but it does welcome families to tour the space and offers respite care for short stays.
Lotus Villa's Memory Care unit provides support for people with dementia, aspiration, swallowing disorders, and those recovering from strokes or surgeries like joint replacement. Rehabilitation services help to prevent falls, and there's a 24-hour call system for emergencies. Residents get a full calendar of activities seven days a week, like games, fitness classes, social gatherings, educational events, wellness programs, entertainment, and church services, with offsite devotional services available too. The facility has a strong focus on making these activities fun, encouraging friendships, and supporting each other, and all activities help residents stay connected and engaged. Lotus Villa is close to local hospitals, doctors, pharmacies, and community events in Fontana, so medical help is nearby when needed, and transportation services can be arranged.
Personal care is always emphasized, and the home-like setting tries to provide peace of mind for families. The environment is compassionate and supportive, aiming for both independence and dignity for each senior, with staff giving companionship and helping with daily living, housekeeping, and laundry. While pets aren't allowed, the facility does allow two people to share a studio, allowing couples or family members to live together. There's a one-time fee of $1500 when moving in. Lotus Villa provides the basic comforts seniors expect, with plain and solid care for those who need a safe, supportive place with meaningful activities and specialized attention.
People often ask...
Lotus Villa And Memory Care offers competitive pricing, with rates starting at a cost of $6,344 per month.
Lotus Villa And Memory Care offers assisted living and memory care.
There are 18 photos of Lotus Villa And Memory Care on Mirador.
The full address for this community is 9448 Citrus Ave, Fontana, CA, 92335.
Yes, Lotus Villa And Memory Care offers respite care.
Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.
State of California Inspection Reports
75
Inspections
9
Type A Citations
21
Type B Citations
4
Years of reports
11 Aug 2025
11 Aug 2025
Found water was available to residents, with multiple stations and pitchers provided, addressing the dehydration allegation. Found COVID-19 precautions were in place, including testing, quarantining, PPE use, and disinfection, and documentation showed changes in condition were reported to the responsible party, with staff indicating that necessary care was provided.
24 Jul 2025
24 Jul 2025
Investigated four allegations—safeguarding personal items, preventing falls, preventing an altercation, and responding to call lights—and found valuables inventoried with a loss/theft program, fall-risk precautions with rounds and a walker, an altercation between residents, and mixed reports on call-light response times. Found the call-light response allegation to be unsubstantiated.
22 Jul 2025
22 Jul 2025
Determined all five allegations unsubstantiated after reviewing records, interviewing the resident and staff, and observing: the fall was accidental and not due to neglect; rooms were cleaned daily and free from odors; belongings were not found missing; and personal hygiene care was provided with supervision as needed, with showers twice weekly.
06 Jun 2025
06 Jun 2025
Found no evidence to support the allegation of financial abuse of residents, no evidence that staff failed to respond to requests for assistance, and no evidence that staff did not accord dignity to residents.
18 Apr 2025
18 Apr 2025
Found that the first allegation involved a resident sustaining fractures due to insufficient staffing, and the second allegation involved an unsafe environment from a second-floor window that lacked an audible alert. An immediate civil penalty of $500 was assessed, with potential for additional penalties after review.
§ 1569.49(f)
§ 87705(j)
18 Mar 2025
18 Mar 2025
Identified that a fire clearance was approved for one bedridden resident, and the site’s capacity remains six. A new license will be issued to reflect one bedridden and five ambulatory residents.
07 Feb 2025
07 Feb 2025
Identified as unsubstantiated the allegation that a resident sustained multiple falls due to lack of supervision. Records showed the resident could ambulate with a walker and received escorting and two-hour observation, and interviews with staff and other residents found no evidence of mistreatment or aggression.
22 Jan 2025
22 Jan 2025
Found that the diaper rash allegation involved a resident who developed a rash after being left in a soiled diaper, with photos showing redness in the groin area. Found insufficient evidence to prove neglect or lack of supervision related to a rib fracture after two falls on 9/1/2024 and 9/3/2024, with residents and staff denying neglect.
§ 87411(a)
08 Nov 2024
08 Nov 2024
Found the home operated as approved, with 24/7 staff coverage and a clean, safe environment. Reviews of four residents’ files and two staff files showed proper documentation and clearances, and medications were dispensed appropriately; no deficiencies were cited.
06 Nov 2024
06 Nov 2024
Found compliance with licensing standards across the site’s physical environment, food service, care and supervision, and recordkeeping; no deficiencies were cited.
20 Sept 2024
20 Sept 2024
Investigated three allegations: staff did not properly maintain resident records; staff did not follow infection control requirements; and staff did not ensure residents' medications were properly stored and secured. Findings indicated records and medication records were securely kept and properly documented, an infection control plan was in place with no current exposure or treatment for contagious conditions, and all three allegations were unsubstantiated.
20 Jun 2024
20 Jun 2024
Investigated two allegations—staff did not treat a resident with respect and staff slapped a resident—and found them unsubstantiated.
20 Jun 2024
20 Jun 2024
Confirmed allegations of staff mistreatment and physical assault of a resident were found to be unsubstantiated based on interviews and record reviews. Residents and staff denied witnessing or experiencing the alleged incidents.
19 Jun 2024
19 Jun 2024
Identified eviction procedure violations for a resident, including no 30-day notice and no licensing approval. Determined the second allegation about staff refusing to return a resident's personal items to be unsubstantiated.
19 Jun 2024
19 Jun 2024
Confirmed staff failed to follow eviction procedures, but unsubstantiated claim of refusing to return resident's items.
§ 87224(a)(2)
19 Apr 2024
19 Apr 2024
Found that the allegation that staff served food of poor quality is unsubstantiated.
19 Apr 2024
19 Apr 2024
Found no evidence to prove that staff did not properly address a resident’s multiple falls resulting in injuries. Records showed updates to the resident’s needs and service plan and care plan after the falls, and staffing levels were sufficient.
19 Apr 2024
19 Apr 2024
Investigated the allegation that staff did not properly address a resident's multiple falls resulting in injuries; determined the allegation unsubstantiated due to insufficient evidence.
02 Feb 2024
02 Feb 2024
Identified that a staff member with criminal background clearance was not transferred to the site, and the administrator confirmed the staff member was no longer employed. An exit interview was conducted, appeal rights discussed, and a deficiency with a $100 civil penalty issued for the failure to transfer and associate the staff member.
§ 87355(e)(2)
02 Feb 2024
02 Feb 2024
Determined that care and supervision were not provided to protect a resident during a fall on April 24, 2023. Found that the allegation that staff locked residents in their rooms had no evidence to support it.
02 Feb 2024
02 Feb 2024
Found that care and supervision were lacking for a resident who fell and suffered a head injury, while allegations of staff locking residents in their rooms were unsubstantiated. A civil penalty was imposed for the substantiated violation.
§ 87411(a)
10 Jan 2024
10 Jan 2024
Found neglect resulting in an unexplained injury and a failure to seek timely medical attention for a non-ambulatory resident who was later hospitalized with a broken femur and blood clots.
10 Jan 2024
10 Jan 2024
Confirmed neglect leading to an unexplained injury, with a resident left in pain for four days without timely medical attention, resulting in a citation and a civil penalty.
§ 87465(2)
§ 87411(a)
18 Dec 2023
18 Dec 2023
Identified that staff did not notify the resident's responsible party in a timely manner after an incident. Found no medical treatment documentation after the fall incident and, per video, staff did not choke the resident but pushed with an open hand to the neck, causing a fall; the timely notification allegation is substantiated, and the choking allegation is unsubstantiated.
18 Dec 2023
18 Dec 2023
Confirmed allegation of staff causing injury to a resident. Identified failure to seek medical attention for the resident. Determined that staff did not notify the responsible party of an incident in a timely manner.
§ 87465(2)
§ 87211(2)
§ 80072(3)
15 Nov 2023
15 Nov 2023
Found the premises in good repair with safe indoor and outdoor spaces, proper lighting, secure medication storage, functioning smoke and carbon monoxide alarms, and adequate furnishings and supplies for residents. Completed pre-licensing requirements with no corrections needed and the Comp III presentation finished.
15 Nov 2023
15 Nov 2023
Conducted pre-licensing visit, found no issues, facility in good condition.
08 Nov 2023
08 Nov 2023
Found compliance with licensing rules at the home; two staff and five residents were present, with rooms furnished and safety measures functioning. Records for residents and staff were reviewed, medications dispensed appropriately, and no deficiencies cited.
08 Nov 2023
08 Nov 2023
Found no deficiencies during the inspection of the facility, ensuring safe and appropriate living conditions for the residents.
13 Oct 2023
13 Oct 2023
Identified adequate staffing to meet resident needs, with a third-party agency used as needed. Found no evidence that staff caused bruising, while two unwitnessed falls occurred among a resident listed as fall risk.
13 Oct 2023
13 Oct 2023
Found insufficient evidence to support allegations of inadequate staffing and unexplained bruises.
20 Sept 2023
20 Sept 2023
Identified concerns that the wheelchair was not cleaned thoroughly, a shirt was used to wipe the floor, the resident was left in a soiled diaper, and inappropriate comments were made about the resident, with floors and a restroom observed as not properly cleaned. Found that the claim that staff could not meet the resident's needs was not established.
20 Sept 2023
20 Sept 2023
Confirmed issues of inadequate cleaning of a resident's wheelchair and facility by staff, and using a resident's personal items to clean spills; however, allegations of inappropriate comments, leaving a resident in soiled diapers for extended periods, unclean rooms, and unmet resident needs were not proven due to insufficient evidence.
§ 80072(1)
§ 87464(d)
§ 87303(a)
30 Aug 2023
30 Aug 2023
Identified multiple safety and credential deficiencies during a pre-licensing visit, including non-working lights in two dining rooms, a partially collapsing second-floor area, broken windows, blocked exits, unlocked chemicals, and doors left unsecured. Water temperatures varied outside acceptable limits, hot water was unavailable in the main restroom, an exterior gate lock was placed without approval, and missing CPR training plus criminal record clearance were found in personnel records, with eight deficiencies issued and a follow-up visit planned for 9/29/23.
30 Aug 2023
30 Aug 2023
Identified deficiencies in physical safety, environmental conditions, and staff records during the inspection. Deficiencies must be corrected by a specified date.
§ 87307(d)(6)
§ 87412(g)
§ 87303(e)(2)
§ 87203
§ 87705(j)
§ 87309(a)
§ 87303(a)
§ 87355(j)
12 Aug 2023
12 Aug 2023
Identified the first allegation of improper medication recordkeeping as supported by evidence. The second allegation about disposal of expired medications and the third about staff training on medication assistance had insufficient evidence.
12 Aug 2023
12 Aug 2023
Confirmed improper record-keeping of medications distributed and disposal of expired medications; allegations of incorrect medication dispensing were not substantiated. Unsatisfactory training for staff on medication assistance remains inconclusive.
§ 87465(3)
05 Jul 2023
05 Jul 2023
Identified that two staff members with criminal background clearance were employed but not transferred to or associated with the site, having been employed since January 1, 2023 and April 21, 2023. Imposed penalties of $500 per person, with daily penalties of $100 continuing until corrected.
05 Jul 2023
05 Jul 2023
Identified lack of transfer of criminal background clearance for two staff members at the facility. Civil penalties assessed and ongoing until corrected.
§ 87355(e)(2)
13 Jun 2023
13 Jun 2023
Verified identification and confirmed that the applicant and administrator understood licensing laws, with photo IDs provided.
Reviewed understanding of licensing requirements across operation, admission policies, staffing and training, restrictive health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness.
13 Jun 2023
13 Jun 2023
Confirmed understanding of facility operation, admission policies, staffing requirements, training, and emergency preparedness during COMP II inspection.
24 May 2023
24 May 2023
Identified gaps in documentation and care, including an outdated physician's report for a resident. Found concerns that staff did not safeguard a resident's personal property, did not ensure attendance at scheduled doctor appointments, and mismanaged medications.
24 May 2023
24 May 2023
Found allegations related to staff not addressing changes in residents' health conditions, not ensuring resident attendance at doctor appointments, and mismanaging resident medications during an inspection.
§ 87465(1)(2)
§ 87465(e)
27 Apr 2023
27 Apr 2023
Found adequate staffing and no imminent health or safety concerns at the site. Observed a safe outside perimeter and food supplies with a three-day stock of perishable items and seven days of non-perishable items, with residents' needs appearing to be met.
27 Apr 2023
27 Apr 2023
Confirmed no health and safety concerns during the visit. Residents' needs were observed to be adequately met.
26 Apr 2023
26 Apr 2023
Found no health or safety hazards or imminent concerns during the visit. Observed adequate staffing and three-day supply of perishable food and seven-day supply of non-perishable food to meet residents’ needs.
26 Apr 2023
26 Apr 2023
Conducted unannounced health and safety check. No imminent concerns observed. Needs of residents met.
07 Apr 2023
07 Apr 2023
Identified that staff did not arrange dental care for a resident, did not assist with the resident’s oral hygiene, and did not provide grooming care. Observed inflamed gums and overgrown nails indicating inadequate care.
07 Apr 2023
07 Apr 2023
Confirmed that staff did not ensure residents received dental care, did not assist with oral hygiene, and did not provide grooming care.
§ 87465(a)(1)
§ 87464(c)(4)
29 Mar 2023
29 Mar 2023
Investigated three allegations by interviewing staff and residents and reviewing plans. For the first allegation, no evidence of staff verbal altercations with residents was found; for the second, infection control measures were in place and there have been no COVID-19 cases since 2/7/2023; for the third, residents reported needs are met and scheduling shows adequate coverage.
29 Mar 2023
29 Mar 2023
Investigated allegations that staff engaged in verbal altercations with residents, failed to prevent the spread of communicable diseases, and lacked adequate staffing; all allegations were deemed unsubstantiated, as there was insufficient evidence to support them.
22 Mar 2023
22 Mar 2023
Determined the allegation that a resident sustained unexplained bruises while in care; interviews and record review did not establish a preponderance of evidence to prove the incident occurred.
22 Mar 2023
22 Mar 2023
Identified that the first allegation—resident sustained an unexplained head injury on 3/1/23 after a fall, with video showing the fall and immediate care provided. Identified that the second allegation—staff did not properly report incidents—had documentation showing notifications to the administrator and the responsible party on dates including 1/11/23, 1/28/23, and 3/1/23.
22 Mar 2023
22 Mar 2023
Confirmed unexplained bruises on a resident were reported but lacking evidence to determine their cause.
02 Mar 2023
02 Mar 2023
Found no evidence to support Allegation 1 that staff handled residents in a rough manner, Allegation 2 that residents were not properly cared for, Allegation 3 that the home was dirty, Allegation 4 that the administrator was not qualified, or Allegation 5 that the home was malodorous.
02 Mar 2023
02 Mar 2023
Found cold conditions in several rooms due to heating issues, with residents reporting their rooms were cold while heaters were being serviced. Found interviews with staff and residents showed respectful care and no observed risky behavior, and noted that no portable heaters were provided for temporary use.
02 Mar 2023
02 Mar 2023
Confirmed uncomfortable temperatures in rooms and unsubstantiated staff risk behavior allegations.
§ 87303
18 Nov 2022
18 Nov 2022
Found the home prepared for licensure, with suitable bedrooms, bathrooms, kitchen, living areas, and secure storage, and safety measures in place.
18 Nov 2022
18 Nov 2022
Confirmed that the facility met all required standards for licensing, including appropriate bedroom furnishings, heating/cooling systems, kitchen supplies, and emergency procedures.
09 Nov 2022
09 Nov 2022
Confirmed COMP II completed for the applicant and administrator via telephone, identity verified, and understanding of Title 22 established; advised to submit signed documentation with a photo ID.
09 Nov 2022
09 Nov 2022
Confirmed successful completion of COMP II for an RCFE application, with understanding demonstrated on various operational aspects.
17 May 2022
17 May 2022
Investigated Allegation 1 about residents’ falls and Allegation 2 about staff not meeting residents’ needs. Found not a preponderance of evidence to prove Allegation 1, given observed fall risks and incident reporting, and not a preponderance of evidence to prove Allegation 2, given staff collaboration with responsible parties and available safety features such as call buttons and rails.
17 May 2022
17 May 2022
Reviewed allegations of resident falls and unmet needs, finding insufficient evidence to confirm violation claims.
28 Mar 2022
28 Mar 2022
Investigated the allegation that the licensee refused to accept a resident back into care; found the resident was not readmitted from the hospital within three days after discharge, and a citation was issued.
28 Mar 2022
28 Mar 2022
Confirmed Licensee refused to accept client back into care.
§ 87224(a)
04 Jan 2022
04 Jan 2022
Reviewed infection-control measures, including posted guidelines, a current PPE supply, daily temperature checks, and ongoing COVID-19 testing and symptom screening at the site. Noted that staff had not been fit tested for N95 masks, and some residents were not wearing masks indoors.
04 Jan 2022
04 Jan 2022
Confirmed all COVID-19 infection control measures were in place and being followed by staff and residents during the inspection.
13 Aug 2021
13 Aug 2021
Found that staff assisted with feeding as needed, supervision was adequate, belongings were safeguarded with the responsible party picking up items upon discharge, centrally stored medications remained locked, linens were changed twice weekly with adequate supplies, and each room had a functioning call system with responders within five minutes. There was not a preponderance of evidence to prove violations occurred, so the allegations were unsubstantiated at this time.
13 Aug 2021
13 Aug 2021
Reviewed allegations of inadequate care and supervision, as well as mishandling of belongings. Inspected medication storage, linens, and signal system, finding no violations.
27 Apr 2021
27 Apr 2021
Reviewed topics included admitting adults under 59, hospice restrictions, bedbound admissions with fire clearance for non-ambulatory status, and administrator paperwork. Noted that bedbound admissions require prior contact with the licensing analyst and that admitting anyone under 59 requires express permission; an Administrator Packet was requested, and a referral to TSP was accepted.
27 Apr 2021
27 Apr 2021
Confirmed issues related to admitting adult residents under 59 years old, hospice restrictions, admission of bedridden residents, and documentation for the new Administrator.
22 Apr 2021
22 Apr 2021
Identified a second adult death under age 60 within 30 days at the residence and requested the January 2021–present Resident Roster along with related records and administrator clearance ID due to a recent administrative change, with an informal meeting scheduled for 4/27/21.
22 Apr 2021
22 Apr 2021
Investigated the death of an adult under 60 at a facility via tele-visit due to COVID-19, requesting relevant documents and scheduling an informal meeting after a recent similar incident.
06 Apr 2021
06 Apr 2021
Investigated a resident's death via tele-visit, requested several documents from the resident's file, and noted the administrator was unsure whether a coroner's report was requested, with plans to update and provide the death certificate when available.
06 Apr 2021
06 Apr 2021
Confirmed a Case Management tele-visit was conducted to collect information regarding an adult death, with requested documents provided for review.
