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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004037
Report Date: 03/03/2022
Date Signed: 03/03/2022 04:48:07 PM


Document Has Been Signed on 03/03/2022 04:48 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 CARE, HUNTINGTON BEACHFACILITY NUMBER:
306004037
ADMINISTRATOR:RITA LEEFACILITY TYPE:
740
ADDRESS:7092 BLUESAILS DRIVETELEPHONE:
(949) 636-8007
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 5DATE:
03/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Myra Miciano, caregiver
Rita Lee, administrator		TIME COMPLETED:
05:00 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
Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by caregiving staff Myra Miciano after explaining the purpose of the visit. Staff called Administrator Rita Lee who arrived at approximately 4:20pm.

At approximately 4:00pm, LPA accompanied by caregiver Myra Miciano began the tour of the facility. There are currently five (5) residents in care, including one (1) on hospice. Residents are observed relaxing in their bedrooms or in the common areas and appears well taken care of. Facility appears to be clean, sanitary and free of odors in all areas inspected. Each bedroom is observed to have all required components and bathrooms are equipped with grab bars and slip mats.

LPA observed a check-in station next to the entrance of the facility where temperature checks are being documented for visitors. LPA observed the facility has COVID-19 Precautions posters, all required department postings and hand washing signs posted throughout. An outdated Administrator certificate was immediately replaced with the current version expiring in July 2022.
LPA observed a sufficient supply of food and water. A 30-day supply of medication is stored and locked. Facility has an adequate supply of PPE in the attached garage. LPA toured the outside of the facility. Outdoor space is free of debris and well-maintained with self-latching gates that can easily be opened. There is a water fountain outside with running water.

Advisory notes for technical assistance had been issued during the previous annual conducted by LPA Michelle Reed on 02/28/2020 regarding access to the stairway leading to the caregivers' bedrooms upstairs. LPA observed stairway remains accessible, however the only ambulatory resident appears alert enough for access not to constitute an immediate risk. Facility is however advised to reconsider access should the residents in care warrant it.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
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 2


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, HUNTINGTON BEACH
FACILITY NUMBER: 306004037
VISIT DATE: 03/03/2022
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
26
27
28
29
30
31
32
(CONTINUED FROM LIC 809)

The facility has completed and submitted their LIC808 Mitigation Plan on 07/08/2021.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report 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: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2