425801828-2-27-2023-29-AS-RDLN-CPG2Z5-20230227164945

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801828
Report Date: 02/27/2023
Date Signed: 02/27/2023 04:49:52 PM

Document Has Been Signed on 02/27/2023 04:49 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LOTUS VILLA		FACILITY NUMBER:	425801828
ADMINISTRATOR:	THARANGANIE MOHOTTIGE		FACILITY TYPE:	740
ADDRESS:	924 VIA LOS PADRES		TELEPHONE:	(805) 964-4960
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93111
CAPACITY: 6		CENSUS: 5	DATE:	02/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Tharanganie Mohottige, Administrator		TIME COMPLETED:	04:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) De Leon conducted an on site 1 year infection control annual visit to the facility above on 02/27/2023 at 3:45 PM . LPA met with Tharanganie and Wasantha Mohottige, Administrators and explained the purpose of the visit. Administrator took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department. The facility has an entry point at the front door where everyone entering completes sign-in and symptom screening questionnaire. All documentation is kept on-file. The entry station has hand sanitizer and a thermometer. Medications are kept in a locked in mediation cabinet off of the dining room. The dining area is spaced to accommodate distancing between residents when eating meals. The staff screen residents at a minimum of 1 x a day. Increased monitoring is conducted if any change of condition is noted. Signs are posted through out the facility regarding Covid-19. Staff make sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility has several areas for visiting inside, outside and in rooms. The facility also offers virtual and telephone communications to all residents in care. Staff, residents and visitors are informed of the facilities infection control policies. New residents will be tested and negative results received before residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Emergency Disaster plan has all agencies with telephone numbers listed. Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Administrator is in charge of staffing and works on any issues or additional coverage. If any suspected or confirmed cases of Covid-19 are found in the facility staff will be assigned to only work with those quarantined/isolated individuals. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LOTUS VILLA	FACILITY NUMBER: 425801828
	VISIT DATE: 02/27/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. The facility has 5 resident bedrooms, 3 residents rest-rooms all are well stocked with soap, paper towels and hand washing signs. Precautionary droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Trash bins have tight fitting lids. Facility has plans for delivering medications and meals to any quarantined/isolation room. The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Furniture has been moved around to accommodate social distancing. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Staff and Resident records are kept in the locked cabinet of the dining room. The kitchen is clean and sanitary and meets food service requirements. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed. Fire Extinguishers are charged and purchased 01/27/2023. All Personnel working in the facility are cleared.
No deficiencies observed during the visit and all infection control protocols are implemented and being followed.

Exit interview completed and report printed and given to Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2