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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200836
Report Date: 03/09/2024
Date Signed: 03/09/2024 11:50:28 AM

Document Has Been Signed on 03/09/2024 11:50 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:
03/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Alexander Salvador, LicenseeTIME COMPLETED:
11:50 AM
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On 3/9/2024 at 10:35am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Alexander Salvador, licensee, whom arrived at 10:35am and explained the purpose of the visit. The administrator, Leticia Manicdao, arrived at 10:40am. The administrator currently holds a certificate (#6047702735) that expires on 8/26/2024. The facility’s fire clearance was approved for four (4) ambulatory clients. No clients present during inspection.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of four (4) bedrooms and three(3) bathrooms. One (1) bedroom occupied by staff and one (1) room used as an activity room. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 113.7 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 5/13/2023. Fire drill last conducted 2/9/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2024
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: 03/09/2024
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Continued from LIC809.

Five (5) staff records were reviewed all were current and complete. Both client's records were reviewed current and complete. LPA also reviewed P & I.

The following forms to be updated and submitted to CCLD by 3/18/2024:
  • LIC610D Emergency disaster plan (9 pages)
  • LIC500 (Personnel Record)
  • Client Roster
  • LIC308 (Designation of facility Responsibility)
  • Updated facility sketch.


No deficiencies cited during inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024
LIC809 (FAS) - (06/04)
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