<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201327
Report Date: 07/16/2024
Date Signed: 07/16/2024 02:21:21 PM


Document Has Been Signed on 07/16/2024 02:21 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Keith-Al Daniel Orzal, Administrator/ApplicantTIME COMPLETED:
02:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 07/16/24 while at the facility for another reason, Licensing Program Analyst (LPA) D Panlilio conducted a component III presentation with administrator (ADM)/ applicant.

LPA discussed the common deficiencies that residential facilities for the elderly are cited on, Title 22 regulations on infection control, physical plant, personnel requirements on clearances and associations, training, emergency/disaster/food requirements, etc. ADM agrees to comply with Title 22 regulations.

ADM was reminded of the statute that requires CCL to be notified within 5 business days of admitting their first resident. This notification may be done by phone, by mail, or by fax.

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)
Page: 1 of 1