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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408138
Report Date: 05/09/2023
Date Signed: 06/06/2023 01:08:03 PM

Document Has Been Signed on 06/06/2023 01:08 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:LOTUS CARE HOME, INC.FACILITY NUMBER:
366408138
ADMINISTRATOR:ANA SUZZETTE SINOHINFACILITY TYPE:
735
ADDRESS:1019 N. IRIS AVENUETELEPHONE:
(909) 820-2812
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 1DATE:
05/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Sherry Villamac, CaregiverTIME COMPLETED:
02:15 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Lotus Care Home, Inc. unannounced to conduct an Annual Inspection. LPA rang the door bell and was greeted and invited in by staff. LPA introduced self and stated purpose of the visit. Staff introduced themselves as Sherry Villamac, Caregiver. Upon arrival, LPA observed a COVID station equipped with COVID tests, hand sanitizer and PPE. Caregiver informed LPA there was one resident at the facility at time of the visit. Administrator Suzette Sinohin, arrived later during LPA's visit.

The facility includes four (4) rooms. 1 staff room and 3 client bedrooms, 2 bathrooms, a kitchen, dining area, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA conducted a general overall inspection, which included, a tour of the facility grounds and review of staff and resident files.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable 71 degrees in temperature. LPA inspected resident bedrooms; which are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting. LPA inspected resident bathroom; bathrooms were clean and appliances were operating appropriately. Bathroom contained adequate supply of paper products and hand hygiene supplies. LPA tested the temperature from the bathroom and kitchen faucets, which ranged between 104 to 117 degrees F. The facility is equipped with operational smoke detectors and carbon monoxide alarms. LPA tested during visit. Posters such as; the personal rights and disaster plans, Infection Control, Facility License were posted in common areas around the facility. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in secure cabinets and drawers. There was a designated storage space for client/staff files in a secure file cabinet adjacent to the kitchen. Medications were locked and inaccessible to residents. The facility had emergency and first aid kits readily available for residents in care. Theses supplies were observed in the secure attached garage and dining room. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: LOTUS CARE HOME, INC.
FACILITY NUMBER: 366408138
VISIT DATE: 05/09/2023
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Food Service: Non-perishable and perishable food supply is sufficient for number of clients residing in the facility. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.
Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. 1 staff member residents at the facility.
Record Review: LPA reviewed 2 client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 2 staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. P & I funds were counted at random and matched with the ledger. Medications were audited at random and appeared to be dispensed appropriately by staff members. Last fire drill conducted on 3/24/23. Last earthquake drill conducted on 4/15/23. Last fire inspection of facility and fire extinguishers conducted on 4/21/23.

Based on observations, no deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Licensee; signature acknowledges understanding and receipt of report and attachments.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC809 (FAS) - (06/04)
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