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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003557
Report Date: 09/06/2024
Date Signed: 09/06/2024 04:53:27 PM

Document Has Been Signed on 09/06/2024 04:53 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LOTUS SENIOR CAREFACILITY NUMBER:
306003557
ADMINISTRATOR/
DIRECTOR:		RITA LEEFACILITY TYPE:
740
ADDRESS:25422 MARINA CIRCLETELEPHONE:
(949) 636-8007
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Rita Lee, Administrator (via telephone)TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the reason of the visit. Administrator Rita Lee was notified of the visit via telephone and could not assist with the visit in person.

During the inspection, LPA and facility staff conducted a tour of the physical plant and observed the following: The facility is a one-story home with five private bedrooms and one locked staff room. There are two shared bathrooms which are observed to be equipped with grab bars and slip mats. All resident bedrooms have the required furnishings. LPA observed all beds have linen and blankets. Postural supports are present with orders on file.

There are currently five residents admitted to the facility, one of which is receiving hospice care. Bathrooms faucets and toilets are operational. Water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed present on the premises. Fire drills are conducted quarterly.

LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food. Smoke and carbon monoxide detectors tested operational. Fire extinguishers present are observed to be fully charged.

There is adequately shaded outside space with outdoor furniture present. There are self-latching gates on both sides of the house and routes of egress are free of obstructions.

Medication, cleaning products and sharp items are confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed for accuracy.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LOTUS SENIOR CARE
FACILITY NUMBER: 306003557
VISIT DATE: 09/06/2024
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CONTINUED FROM FORM LIC809
LPA reviewed five resident files and three staff files. Resident records include all necessary components. All staff members are confirmed to be cleared and associated with this particular licensed location with up-to-date first aid/CPR training. LPA additionally conducted three resident and two staff interviews.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Two Technical Assistance advisory note are provided with a consultation on the required Infection Control Plan as well as updates to the residents' medical assessments. An exit interview was conducted with the administrator over the phone, and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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