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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202828
Report Date: 10/27/2022
Date Signed: 10/27/2022 03:33:34 PM


Document Has Been Signed on 10/27/2022 03:33 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
CENTRAL COAST CR/RES, 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) 564-7719
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:6CENSUS: 5DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Lori MohasselTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Lori Mohassel and Licensee Ghebresellasie Zenebesh.

During visit, LPA Marrufo toured the inside and outside of the facility. LPA Marrufo observed a perishable food supply of 2 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed a 30-day supply of PPEs. LPA Marrufo observed the hallway bathroom had available soap, paper towels, and a hand washing sign. LPA Marrufo toured the outside of the facility and observed the exits to be clear of obstructions.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Administrator Lori Mohassel and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
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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