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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920024
Report Date: 12/14/2023
Date Signed: 12/14/2023 12:41:51 PM


Document Has Been Signed on 12/14/2023 12:41 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
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: 4DATE:
12/14/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Kulwinder Kaur, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a post licensing inspection. LPA met with Kulwinder Kaur during today's inspection.

LPA toured the facility with administrator and observed 4 residents in care. 3 of 4 residents in care are receiving hospice services. LPA observed 4 resident rooms, kitchen, bathroom, garage, and common living spaces. In the areas toured no immediate health, safety, or personal rights violations were observed. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete. LPA reviewed 1 resident file and 1 staff file. LPA observed a copy of current liability insurance.

No deficiencies cited during today's inspection.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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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