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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200836
Report Date: 02/16/2023
Date Signed: 02/16/2023 11:17:32 AM

Document Has Been Signed on 02/16/2023 11:17 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LOTUS HOMEFACILITY NUMBER:
079200836
ADMINISTRATOR:MANICDAO, LETICIAFACILITY TYPE:
735
ADDRESS:400 LOTUS CTTELEPHONE:
(925) 684-7039
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 4CENSUS: 2DATE:
02/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Leticia Manicdao, Administrator TIME COMPLETED:
11:35 AM
NARRATIVE
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On 02/16/2023 at 9:30AM Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct infection control annual inspection. LPA met with Administrator Leticia Manicdao, LPA explained the purpose of the visit. Facility has census of 2.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility has four bedrooms and 3 bathrooms. One bedroom and bathroom is reserved for staff use only. One bedroom is used as an activity room. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Visitors’ policy is posted on the front entrance. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days. Smoke detectors and carbon monoxide were in operating condition during visit.

Facility has enough supplies of PPEs, paper supplies and hygiene supplies. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan and maintains record of routine screening for clients, visitors and staff.

...continued to LIC809C...

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LOTUS HOME
FACILITY NUMBER: 079200836
VISIT DATE: 02/16/2023
NARRATIVE
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LPA observed the following:
· Administrator do not have proof of covid19 training.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted with Administrator Leticia M. & licensee Alex Salvador A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/16/2023 11:17 AM - It Cannot Be Edited


Created By: Leslie Ibo On 02/16/2023 at 10:45 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LOTUS HOME
FACILITY NUMBER: 079200836

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)(5)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (5) Recognition of early signs of illness and the need for professional assistance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based o interview and records review the licensee did not comply with the section cited above in Administrator failed to provide proof of covid19 training for staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/02/2023
Plan of Correction
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Administrator stated that she will conduct another covid19 training for all staff and document the training. LPA requested proof of training to be sent to CCL via fax by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023


LIC809 (FAS) - (06/04)
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