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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920024
Report Date: 11/01/2023
Date Signed: 11/01/2023 10:36:12 AM


Document Has Been Signed on 11/01/2023 10:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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: 0DATE:
11/01/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Kulwinder Kaur, Administrator TIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived to conduct a pre-licensing inspection. LPA met with licensee Kulwinder Kaur during today's inspection. LPA ensured they applied hand sanitizer before entering the facility.

Facility was inspected both indoors and outdoors. LPA inspected 5 resident bedrooms, 2 bathrooms, common living areas, kitchen, garage, and outdoor areas. Outdoor area is free from hazardous debris. Outdoor exits are clear and accessible. First aid kit was present in the facility. Centrally stored medications will be locked in cabinets near the kitchen and pantry area. LPA inspected resident bedrooms and the bedroom had appropriate furnishings, adequate lighting and storage. Bathrooms are clean, sanitary, and in good repair. Grab bars and non-skid mat was present in all bathrooms. Smoke detectors and carbon monoxide detectors were checked. Fire clearance was granted on 08/24/23 for 6 non-ambulatory residents of which 2 may be bedridden in bedroom 1. Kitchen is clean, sanitary, and in good repair. A working telephone has be set up for residents use.

Licensee agrees to notify LPA once first consumer is admitted. This report will be forwarded to the centralized application unit for continued processing. Comp III was completed today during the inspection.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023
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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