306004037-3-7-2025-22-AS-NGUN-DEJUWR-20250307145710

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004037
Report Date: 03/07/2025
Date Signed: 03/07/2025 02:57:50 PM

Document Has Been Signed on 03/07/2025 02:57 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 CARE, HUNTINGTON BEACH		FACILITY NUMBER:	306004037
ADMINISTRATOR/ DIRECTOR:	RITA LEE		FACILITY TYPE:	740
ADDRESS:	7092 BLUESAILS DRIVE		TELEPHONE:	(949) 636-8007
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92647
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	03/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:09 AM
MET WITH:	Hendrick Catayas, Caregiver		TIME VISIT/ INSPECTION COMPLETED:	03:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Nancy Guillen made an unannounced visit for the purpose of conducting a required annual Inspection. LPA was greeted and granted entry by caregiver Hendrick Catayas after explaining the purpose of the visit. Administrator (AD) Rita Lee was notified and assisted via telephone. LPA observed the Administrator Certificate was current and expires July 31, 2026. This is a Residential Care Facility for the Elderly (RCFE) licensed to six non-ambulatory residents, of which three may be bedridden, with a hospice waiver for four. The facility is a two-story home. The first floor consists of five resident bedrooms, three resident bathrooms, a family room, dinning room, kitchen and garage. The second floor is for staff and consists of three staff bedrooms, one bathroom and a vanity room.

During the inspection, LPA and caregiver Hendrick Catayas toured the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:LPA observed residents watching television in their respective rooms and sitting in the dinning table. LPA observed five residents in care and two staff present. LPA observed the See Something Say Something Poster (PUB 475) mounted on the wall by the entrance to the facility. LPA observed knives to be located in an unlocked drawer in the kitchen; a deficiency was cited on today’s date. All resident bedrooms had the required furnishings. LPA observed four out of five residents had bed rails with no doctor’s orders present at the facility; a deficiency was cited on today’s date. Resident 2 had a camera in his bedroom; a deficiency was cited on today’s date. LPA observed all resident beds had linens and blankets with additional linens stored in Room 1. LPA observed bathrooms were clean and equipped with grab bars and non skid floor mats. LPA observed all windows were appropriately screened. Bathrooms were observed to be free of debris and mildew, faucets and toilets were tested operational. Water temperature tested between 110.8 and 125.6 degrees Fahrenheit; a deficiency was cited on today’s date. LPA toured the outside of the facility and observed outdoor passageways were free of obstruction. LPA observed the backyard had a shaded sitting area with furniture for resident use.

Continued on 809C

Armando J Lucero	TELEPHONE: (714) 703-2866
Nancy Guillen	TELEPHONE: (714) 724-3542
	DATE: 03/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

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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Document Has Been Signed on 03/07/2025 02:57 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LOTUS SENIOR CARE, HUNTINGTON BEACH	FACILITY NUMBER: 306004037
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, staff interview and record review, the licensee did not comply with the section cited above due to TB test not present in two out of three staff files which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2025
	Plan of Correction
1 2 3 4	Caregiver stated TB tests will be provided to LPA via email by POC date.

Section Cited

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Armando J Lucero	TELEPHONE: (714) 703-2866
Nancy Guillen	TELEPHONE: (714) 724-3542
	DATE: 03/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

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, HUNTINGTON BEACH	FACILITY NUMBER: 306004037
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on water temperature reading, the licensee did not comply with the section cited above in two out of three resident restrooms, which poses an immediate health, safety or personal rights risk to persons in care. Two resident restrooms measured 125.6 degrees Fahrenheit.
	POC Due Date: 03/10/2025
	Plan of Correction
1 2 3 4	Caregiver stated a video recording will be sent to LPA via email by POC date with corrected water temperature in all resident restrooms. Licensee to submit a record log to LPA by March 17, 2025 of daily temperature reading log to LPA via email.

Type A

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety and personal rights risk to persons in care. Knives were located in an unlocked drawer in the kitchen accessible to residents in care.
	POC Due Date: 03/07/2025
	Plan of Correction
1 2 3 4	Caregiver removed knives and placed in a locked cabinet. POC was cleared on today's date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Armando J Lucero	TELEPHONE: (714) 703-2866
Nancy Guillen	TELEPHONE: (714) 724-3542
	DATE: 03/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/07/2025 02:57 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LOTUS SENIOR CARE, HUNTINGTON BEACH	FACILITY NUMBER: 306004037
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two out of three staff files which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2025
	Plan of Correction
1 2 3 4	Caregiver stated CPR certifications will be completed by POC date.

Type A

Section Cited

CCR

87458(c)(1)(A)

Medical Assessment

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in three out of five records reviewed which poses an immediate health, safety and personal rights risk to persons in care. (In records for Resident 2, 3, and 4).
	POC Due Date: 03/10/2025
	Plan of Correction
1 2 3 4	Caregiver stated a negative TB test will be sent to LPA via email by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Armando J Lucero	TELEPHONE: (714) 703-2866
Nancy Guillen	TELEPHONE: (714) 724-3542
	DATE: 03/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/07/2025 02:57 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LOTUS SENIOR CARE, HUNTINGTON BEACH	FACILITY NUMBER: 306004037
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and staff interview, the licensee did not comply with the section cited above. Carbon monoxide could not be located at the facility which poses a potential health and safety risk to persons in care.
	POC Due Date: 03/21/2025
	Plan of Correction
1 2 3 4	Caregiver stated a carbon monoxide detector will be placed in the facility.

Type B

Section Cited

CCR

87465(h)(1)(C)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on medication review, the licensee did not comply with the section cited above in three out of five resident's medications, which poses a potential health risk to persons in care. (R1,R2,R4))
	POC Due Date: 03/21/2025
	Plan of Correction
1 2 3 4	Caregiver stated a doctor's order will be emailed to LPA by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Armando J Lucero	TELEPHONE: (714) 703-2866
Nancy Guillen	TELEPHONE: (714) 724-3542
	DATE: 03/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC809 (FAS) - (06/04)

Page: 5 of 9

Document Has Been Signed on 03/07/2025 02:57 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LOTUS SENIOR CARE, HUNTINGTON BEACH	FACILITY NUMBER: 306004037
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87506(b)(10)

Resident Records

(b) Each resident's record shall contain at least the following information: (10) Reports of the medical assessment specified in Section 87458 Medical Assessment, and of any special problems or precautions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one out of five files reviewed which poses a potential health risk to persons in care. Resident 1 missing a Physician's Report.
	POC Due Date: 03/21/2025
	Plan of Correction
1 2 3 4	Caregiver stated a Physician's report will be sent to LPA via by POC date.

Type B

Section Cited

CCR

87507(c)

Admission Agreements

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one out of five records (R1) reviewed which poses a potential personal rights risk to persons in care.
	POC Due Date: 03/21/2025
	Plan of Correction
1 2 3 4	Caregiver stated a completed admissions agreement will be sent to LPA via email by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Armando J Lucero	TELEPHONE: (714) 703-2866
Nancy Guillen	TELEPHONE: (714) 724-3542
	DATE: 03/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/07/2025 02:57 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LOTUS SENIOR CARE, HUNTINGTON BEACH	FACILITY NUMBER: 306004037
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety and personal rights risk to persons in care. Last disaster drill was conducted on August 2nd, 2024.
	POC Due Date: 03/21/2025
	Plan of Correction
1 2 3 4	Caregiver stated a disaster drill will be conducted by POC date and log to be sent to LPA via email.

Type B

Section Cited

CCR

87608(a)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation , the licensee did not comply with the section cited above in four out of five residents which poses potential health and safety risk to persons in care. Bed rails did not have a doctor's orders available for review during visit.
	POC Due Date: 03/21/2025
	Plan of Correction
1 2 3 4	Caregiver stated bed rail orders for R1,3,4,and 5 will be sent to LPA via email by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Armando J Lucero	TELEPHONE: (714) 703-2866
Nancy Guillen	TELEPHONE: (714) 724-3542
	DATE: 03/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC809 (FAS) - (06/04)

Page: 7 of 9

Document Has Been Signed on 03/07/2025 02:57 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LOTUS SENIOR CARE, HUNTINGTON BEACH	FACILITY NUMBER: 306004037
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87468.2(a)(1)

(a) In addition to the rights listed in Section 87468.2, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview of caregiver, the facility utilizes a camera in one out of five bedrooms and is not providing R2 a reasonable level of personal privacy which poses a potential personal rights risk to persons in care.
	POC Due Date: 03/07/2025
	Plan of Correction
1 2 3 4	Camera was immediately removed by caregiver. POC cleared on today's visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

Armando J Lucero	TELEPHONE: (714) 703-2866
Nancy Guillen	TELEPHONE: (714) 724-3542
	DATE: 03/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC809 (FAS) - (06/04)

Page: 9 of 9

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, HUNTINGTON BEACH	FACILITY NUMBER: 306004037
	VISIT DATE: 03/07/2025

NARRATIVE

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LPA observed the facility had a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors tested operational, however a carbon monoxide detector was not located at the facility; a deficiency was cited on today’s date. Fire extinguisher was observed to be fully charged with a service date of February 20, 2025 and located in the family room. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be locked and inaccessible to residents under the kitchen sink. Medication cabinet was observed to be locked and centrally stored in the kitchen however, PreserVision and Iprat-Albut was being administered to residents without a doctor’s order present at the facility; a deficiency was cited on this date. LPA observed the First Aid Kit had all the required components. LPA observed the facility conducted their last emergency disaster drill on August 2, 2024; a deficiency was cited on today’s date. Liability insurance was not present at the facility; a Technical Violation was given on today’s date.

LPA began review of the records. LPA reviewed five resident records. One out of five records reviewed was missing a Physician’s Report and an admissions agreement and three of the five records reviewed were missing negative TB tests; deficiencies were cited on today’s date. LPA reviewed three employee records. All employee’s present have a criminal record clearance and were associated to the facility. However, all staff CPR certifications were observed expired ; a deficiency was cited on today’s date. Two of the staff present today did not have a negative TB test present at the facility; a deficiency was cited on today’s date.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2866
LICENSING EVALUATOR NAME: Nancy Guillen	TELEPHONE: (714) 724-3542
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC809 (FAS) - (06/04)

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