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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920024
Report Date: 09/28/2023
Date Signed: 09/28/2023 08:18:42 PM


Document Has Been Signed on 09/28/2023 08:18 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:LOTUS VILLA CARE HOMEFACILITY NUMBER:
315920024
ADMINISTRATOR:KAUR, KULWINDERFACILITY TYPE:
740
ADDRESS:5025 CANNING WAYTELEPHONE:
(916) 807-4690
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: DATE:
09/28/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kulwinder KaurTIME COMPLETED:
02:30 PM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): none
COMP II Participants: Kulwinder Kaur, Lic/Administrator
Interview Method: Telephone interview

On September 28, 2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.
SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Dianne RamosTELEPHONE: (916) 653-5973
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
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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