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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201327
Report Date: 07/16/2024
Date Signed: 07/16/2024 02:20:34 PM


Document Has Been Signed on 07/16/2024 02:20 PM - 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 HEARTS HOME CAREFACILITY NUMBER:
079201327
ADMINISTRATOR:ORZAL, KEITH-AL DANIELFACILITY TYPE:
740
ADDRESS:3127 LISA COURTTELEPHONE:
(415) 243-7219
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 0DATE:
07/16/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Keith-Al Daniel Orzal, Administrator/ApplicantTIME COMPLETED:
02:50 PM
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On 07/16/24 at 11:30AM. Licensing Program Analyst (LPA) Daisy Panlilio arrived unannounced to conduct a pre-licensing inspection. LPA met with Administrator/Applicant (ADM) and explained the purpose of the visit. ADM has a current administrator certificate # 6068864740 which expires 04/04/26. Fire clearance was granted on 11/07/23 for 6 non-ambulatory residents. Facility currently has no residents.

LPA toured the facility with ADM including but not limited to the residents' bedrooms, common areas, kitchen, and outdoor area. LPA observed a screening station near the front entrance with a no touch temperature probe, visitors' log and hand sanitizer. Facility has adequate lighting. Indoor and outdoor passageways were observed free of obstruction. LPA observed hot water temperature at 119 degrees F. LPA observed 2 days supply of perishable and one week supply of non-perishable foods. Towels, sheets, activity supplies and hygiene products were observed available. The facility has 2 full bathrooms. LPA observed the shower area has non-skid floor tiles. There are activity materials observed in the living room. Facility has flashlights available for emergency use. LPA observed sufficient emergency supplies stored inside the garage. There is sufficient lighting throughout facility. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was observed fully charged. Proper hand-washing signs, Emergency/Disaster plans/contact information, personal rights were observed posted in common areas.

LPA observed no deficiencies during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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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