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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920024
Report Date: 02/12/2024
Date Signed: 02/12/2024 11:44:04 AM


Document Has Been Signed on 02/12/2024 11:44 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: 3DATE:
02/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kulwinder Kaur, AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with Administrator Kulwinder Kaur during today's inspection.

LPA arrived to collect more information and documentation on resident that has been placed on hospice care. LPA reviewed staff training, resident documents, and staff documentation. Resident was receiving home health care and now will be receiving hospice care services. LPA toured the facility and in the areas toured no immediate health, safety, or personal rights violations were observed.

No deficiencies cited during today's inspection.

Exit interview conducted and copy of report provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
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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