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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003557
Report Date: 08/01/2022
Date Signed: 08/01/2022 04:46:35 PM


Document Has Been Signed on 08/01/2022 04:46 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:LOTUS SENIOR CAREFACILITY NUMBER:
306003557
ADMINISTRATOR:RITA LEEFACILITY TYPE:
740
ADDRESS:25422 MARINA CIRCLETELEPHONE:
(949) 636-8007
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
08/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Belinda Rilengado, caregiver
Evelyn Deldio, caregiver 		TIME COMPLETED:
05:00 PM
NARRATIVE
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On 08/01/2022 at 3:00pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by Belinda Rilengado, caregiver and Evelyn Deldio, caregiver after explaining the purpose of the visit. Administrator Rita Lee was called and notified of the visit but could not join in person.

At approximately 3:10pm, LPA accompanied by caregivers toured the physical plant of the facility. LPA observed a check-in station at where visitor temperatures are being documented. There are currently four (4) residents in care, none of which are receiving hospice care. Residents are observed relaxing in their respective bedrooms and appear clean and well taken care of. The bedrooms include all necessary components. Bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected.

Sharp instruments are stored in a locked kitchen drawer. LPA observed a sufficient supply of food and water. A 30-day supply of medication is centrally stored in a closet next to the kitchen. Cleaning supplies are located in the laundry room. During the visit, both the door leading to the laundry room and to the centrally stored medication were observed to be unlocked. LPA observed the facility has COVID-19 Precautions posters and all required department postings as well as hand-washing signs in the bathrooms. Facility has an adequate supply of PPE.

CONTINUED ON FORM LIC809-C
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022
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 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LOTUS SENIOR CARE
FACILITY NUMBER: 306003557
VISIT DATE: 08/01/2022
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CONTINUED FROM LIC809

The two caregiver present are part of the reliever team rather than the permanent staff. Staff S1 is shown to be cleared and associated correctly to the facility, however caregiver S2 is cleared but has not been associated to the facility in Guardian. LPA toured the outside of the facility and observed it to be free of obstructions. The perimeter gates are self-latching but are being secured by carabiniers on the inside of the yard, slowing down the possibility of egress in an emergency. Upon LPA's request, staff member removed the carabiniers from the gates' latches. There is a fountain but no bodies of standing water are present on the premises.

Based on the observations and file review conducted during today’s visit, two (2) type A and one (1) type B deficiencies are being cited and one (1) Technical Advisories are issued per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report along with appeal rights was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/01/2022 04:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: LOTUS SENIOR CARE
FACILITY NUMBER: 306003557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Section 87705(f)(1) of the California Code of Regulation indicates that "(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s)."

This requirement is not met as evidenced by the access doors to both the medication central storage and the laundry room are both observed to have been left unlocked by the attending staff.
Deficient Practice Statement
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Based on the observations made during today's visit, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2022
Plan of Correction
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2
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Licensee will ensure that the access doors to the laundry room and the medication central storage are locked at all times when not attended to directly by staff.
Type A
Section Cited
CCR
87355(e)
The California Code of Regulations Section 87355(e) indicates that "All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)"

This requirement is not met as evidenced by the review of associated staff not including staff member S2.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2022
Plan of Correction
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Licensee will request the transfer of a criminal record clearance for staff member S2 before 08/02/2022 by end of business.

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: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 08/01/2022 04:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: LOTUS SENIOR CARE
FACILITY NUMBER: 306003557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not being met as evidenced by carabiniers installed on the gates latches which would necessitate an additional step of two-handed operations but no additional tool or key to allow for an evacuation
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2022
Plan of Correction
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Carabiniers will be removed by licensee and staff will be instructed to not interfere with the optimal operation of the backyard exit gates.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5