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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202828
Report Date: 09/28/2021
Date Signed: 09/28/2021 04:58:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LOTUS GARDEN CARE HOMEFACILITY NUMBER:
435202828
ADMINISTRATOR:MOHASSEL, LORIFACILITY TYPE:
740
ADDRESS:2119 MONROE STREETTELEPHONE:
(408) 218-2609
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:6CENSUS: 0DATE:
09/28/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Zenebesh Ghebresellasie and Lori MohasselTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted a pre-licensing inspection today. LPA met with licensee Zenebesh Ghebresellasie and Administrator (ADM) Lori Mohassel.

At around 10:15am, LPA toured the facility inside and out. A screening station is observed by the entry door for anyone coming in the facility.

The facility is equipped with connected smoke and carbon monoxide detectors. The smoke/carbon monoxide detector located in the hallway was tested and observed working. Several fire extinguishers were observed in the home which were all serviced on 08/16/21. The kitchen, dining and living room were observed in good repair.

Resident bedrooms were observed in good repair, furnished, with clean linens and adequate lighting. Bathrooms were observed clean and equipped with grab bars. The water temperature in the kitchen was measured at 119.1 degrees F. Centrally stored medication cabinet, and a cabinet with non-perishable were observed in the kitchen. Emergency food supplies and PPEs were observed in the garage. The facility has a generator for emergency. A complete first aid kit was inspected. All outdoor and indoor passageways were observed clear and free of obstruction. The backyard was inspected, no bodies of water observed.

Component III orientation was completed with licensee and ADM. No issues noted during the pre-licensing tele-inspection. The physical plant is approved pending the completion of Centralized Application Bureau (CAB) review of the facility application. Exit interview conducted with and copy of report provided to Zenebesh Ghebresellasie.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne RoadillaTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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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