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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801828
Report Date: 02/21/2024
Date Signed: 02/22/2024 09:33:33 AM


Document Has Been Signed on 02/22/2024 09:33 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:LOTUS VILLAFACILITY NUMBER:
425801828
ADMINISTRATOR:THARANGANIE MOHOTTIGEFACILITY TYPE:
740
ADDRESS:924 VIA LOS PADRESTELEPHONE:
(805) 964-4960
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY:6CENSUS: 5DATE:
02/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Wasantha MohottigeTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection to the above-named facility. Upon arrival, LPA was greeted by Staff 1 (S1). Administrator Wasantha Mohottige arrived at approximately 12:30 PM. Tharangine Mohottige arrived at 12:45 PM. LPA inspected the one-story facility for fire safety, personal accommodations, and food service.

Entrance interview conducted.
There are currently five (5) residents residing in the facility. Currently, there are no residents on hospice, four (4) non-ambulatory residents and one (1) ambulatory resident. At the time of arrival, there was one (1) staff available in the facility and five (5) residents present in the facility.
LPA toured the facility with Administrator. LPA observed five (5) resident bedrooms, and one (1) staff bedroom. Bedrooms #1, 2, and 4 are private rooms with private bathrooms. Bedrooms 3 and 5 are private bedrooms with a shared bathroom off the hallway.
Walls, floors, and doorways are clean with no safety hazards. The kitchen area consists of a countertop area, a refrigerator, a stove, a microwave, and a sink. Sharps and centrally stored medications are kept in a locked cabinet in the dining area with no access to residents. First aid kit was observed to be complete. Fire inspection was current as of 1/22/2024.
There is a sufficient amount of perishables for seven (7) days and non-perishables for two (2) days. Emergency food is stored in a second refrigerator and pantry located in the garage. There is a washing machine and a clothes dryer in the garage. Chemicals and toxic substances are kept in a locked cabinet under the kitchen sink.
The facility has ten smoke alarms and one carbon monoxide detector. The living room and dining area are neat and clean. The facility maintains a comfortable temperature. Hallways, bedroom doors and walls are in good repair.
Please continue to 809-C, Pg 2.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LOTUS VILLA
FACILITY NUMBER: 425801828
VISIT DATE: 02/21/2024
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 The living room and dining area are neat and clean. The facility maintains a comfortable temperature. Hallways, bedroom doors and walls are in good repair.
A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights, Ombudsman contact, and Resident’s Rights. Caregiver duties and responsibilities are posted in the kitchen area.
Residents may participate at will in activities such as personal care appointments, medical appointments, games, exercising, neighborhood walks, sitting on the patio, outdoor excursions to parks, beaches, and shopping at local retail businesses.
The backyard consists of pebble embedded ramps, a picnic table, and fruit trees in a shaded area. The recycling bin, green waste bin, and trash bins are standard bins with flip lids.

Exit interview conducted. Technical violations were noted. Copy of report issued at the time of the visit.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC809 (FAS) - (06/04)
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