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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408138
Report Date: 05/09/2024
Date Signed: 05/09/2024 12:15:53 PM

Document Has Been Signed on 05/09/2024 12:15 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:LOTUS CARE HOME, INC.FACILITY NUMBER:
366408138
ADMINISTRATOR/
DIRECTOR:		ANA SUZZETTE SINOHINFACILITY TYPE:
735
ADDRESS:1019 N. IRIS AVENUETELEPHONE:
(909) 820-2812
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 4DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Licensee/Administrator Ana Suzzette SinohinTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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On 05/09/2024 at 9:50 AM, Licensing Program Analysts (LPAs) Melody Brown and Sarina Ramirez conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPAs Brown and Ramirez were greeted by a staff and gained access at the home. Licensee/Administrator Ana Suzzette Sinohin was informed of the visit. LPAs Brown and Ramirez explained the purpose of the visit to Licensee/Administrator Sinohin.

The facility has four (4) bedrooms,two (2) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPAs Brown and Ramirez completed a walkthrough of the facility, review of records, P&I, audit, and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Brown and Ramirez observed no clients during the visit. Licensee/ Administrator Sinhoin informed LPAs that their clients’ are out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 72 degrees Fahrenheit. LPAs Brown and Ramirez inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting, however LPAs Brown and Ramirez observed no reading lamp in Client 3 (C3) and Client 4 (C4) room. Technical violation will be issued. LPAs Brown and Ramirez inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 118 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in a locked container inaccessible to clients. LPAs Brown and Ramirez observed no night lights at the hallway leading to clients' shared bathrooms. Deficiency will be
*** Continuation in LIC809C ***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: LOTUS CARE HOME, INC.
FACILITY NUMBER: 366408138
VISIT DATE: 05/09/2024
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issued. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPAs observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPAs Brown and Ramirez reviewed two (2) client files for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP). LPAs Brown and Ramirez observed files reviewed were complete. LPAs Brown and Ramirez also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPAs Brown and Ramirez observed no issues, files reviewed were complete.

LPAs Brown and Ramirez audited two (2) clients’ medications and no issues were observed. LPAs Brown and Ramirez audited two (2) client's P&I and no issue observed.

Deficiency and Technical Violation were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and Appeal Rights were discussed, and copies were provided to Licensee/Administrator Ana Suzzette Sinohin.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2024 12:15 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 05/09/2024 at 11:35 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LOTUS CARE HOME, INC.
FACILITY NUMBER: 366408138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not having night lights maintained in hallways and passages to nonprivate bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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Licensee stated to purchase night lights and submit proof to LPAs Brown and Ramirez at Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024


LIC809 (FAS) - (06/04)
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