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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202828
Report Date: 10/23/2023
Date Signed: 10/24/2023 08:11:41 AM


Document Has Been Signed on 10/24/2023 08:11 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
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: 6DATE:
10/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Administrator Lori Mohassel and Licensee Zenebesh GhebresellasieTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Administrator (ADM) Lori Mohassel and Licensee (LIN) Zenebesh Ghebresellasie. LPA Rai stated the purposed of today's visit. LPA Rai observed 3 staff in the facility, 3 residents sitting in living room, 1 resident sitting in the dining room, and 2 residents in the resident's rooms. At this time there is one resident under Hospice services.

During visit, LPA Rai toured the inside and outside of the facility with LIN and ADM. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed secured areas for cleaning supplies and laundry detergents in the garage area. LPA Rai observed oxygen tank in resident R3's room. ADM stated R3 does not use oxygen tank and the oxygen supplier company will pick up the supplies from the resident's room.

The facility bathroom had available soap, paper towels, and trash cans with lids. The shower had grab bars and non-skid mats. The water temperature in the bathroom sinks ranged from 105.6F-106.5F. Facility smoke detectors and carbon monoxide detectors were in working condition. 6 out of 6 resident bedrooms had available bedding, drawers, and functioning lights.

LPA Rai reviewed facility records for 3 residents. LPA observed 2 residents did not have a completed appraisal/needs and services plan since their admission date. ADM and LIN could not located a completed appraisal/needs and services plan. ADM and LIN stated they will follow up with the resident's responsible party to create an appraisal/needs and services plan.

Continuation on LIC 809-C, Page 1 of 3.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023
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 6


Document Has Been Signed on 10/24/2023 08:11 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 435202828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(a)
87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, interview and observation R1's 2 out of 5 medication, R2's 1 out of 5 medications and R3's 2 out of 2 medications were not administered to residents as prescribed by the MD which poses an immediate Health, Safety, or Personal Rights risk to persons in care..
POC Due Date: 10/24/2023
Plan of Correction
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Licensee and Administrator stated they will submit a written plan on understanding regulations and schedule in-services and medication training to staff by POC date. Licensee and Administrator agreed and understood.
Type A
Section Cited
CCR
87207
87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, interview and observation, 3 out of 3 resident's medications were counted during today's visit, the tablets/capsules in the prescription bottle did not match the doses given 3 residents based on the Medication Administration Record (MAR). This concludes the facility staff noted doses were given to residents when medication was not adminstered, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
POC Due Date: 10/24/2023
Plan of Correction
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Licensee and Administrator stated they will submit a written plan on understanding regulations and schedule in-services and training to staff by POC date. Licensee and Administrator agreed and understood.
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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 10/24/2023 08:11 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 435202828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
87457 Pre Admission Appraisal- General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above when out 2 of 6 resident files did not contain needs and services plan since admission which poses a potential health, safety or personal rights risk to persons in care
POC Due Date: 10/30/2023
Plan of Correction
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Licensee and Administrator stated they will provide a written plan for admission procdures for all new residents and will submit to LPA. Licensee and Admnistrator will work with resident's responsible party to complete appriasal / needs and services plan and send to LPA once completed. Licensee and Administrator agreed and understood.
Type B
Section Cited
CCR
87466
87466 Observation of the Resident

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 6 out of the 6 residents did not have record of weight log in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2023
Plan of Correction
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Licensee and Administrator stated they will provide a written plan of action and understanding of regulations by POC date. Licensee and Administrator agreed and understood.
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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 10/24/2023 08:11 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 435202828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements - General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in 3 out of 3 staff did have first aid training from a qualified agency as American Red Cross and staff files did not have a copy of the first aid training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2023
Plan of Correction
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Licensee and Administrator stated they will provide a written plan of action and understanding of regulations by POC date and submit a copy of the first aid training/certification once completed. Licensee and Administrator agreed and understood.
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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 435202828
VISIT DATE: 10/23/2023
NARRATIVE
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Page 2 of 3.
Facility did not maintain a weight log for 6 out of the 6 residents. LPA Rai reminded ADM and LIN need to observe resident for changes and this includes weight loss and weight gain. ADM and LIN will initiate a weight log for the residents to observe changes such as unusual weight gains or losses. LIN stated the facility staff will initiate measurement of resident's arms or thigh's to monitor resident's weight loss and weight gain for residents that are not able to use the regular weight machine.

LPA Rai reviewed resident medications and central stored medication records. LPA Rai, LIN and S1 counted the medications for R1-R3. During a random review/audit of resident's medication bottle and LIC 622 Centrally Stored Medication and Destruction Record, 2 out of 5 medications prescribed to R1 was not given as prescribed by the doctor. LPA Rai along with LIN and S1 counted the tablets from the medication bottles.
R1's medication #1 were counted 64 tablets instead of 61 tablets, which concluded there were 3 extra tablets in the bottle and medication was not administered according to the MD's prescription and order on the prescription bottle. R1's medication #4 were counted 67 tablets instead of 64, which concluded there were 3 extra tablets in the bottle.

1 out of 5 medications prescribed to R2 was not given as prescribed by the doctor. LPA Rai along with LIN and S1 counted the tablets from the medication bottles. R2's medication #3 were counted 58 tablets instead of 52 tablets, which concluded there were 6 extra tablets in the bottle and medication was not administered according to the MD's prescription and order on the prescription bottle.

2 out of 2 medications prescribed to R3 was not given as prescribed by the doctor. LPA Rai along with LIN and S1 counted the tablets from the medication bottles. R3's medication #1 were counted 42 tablets instead of 32 tablets, which concluded there were 10 extra tablets in the bottle and medication was not administered according to the MD's prescription and order on the prescription bottle. R3's medication #2 were counted 10 tablets instead the medication bottle being empty and medication was not administered according to the MD's prescription and order on the prescription bottle.

LPA Rai review facility records for 3 staff. LPA Rai observed 3 staff members did not have first aid training on file. ADM and LIN stated the facility staff have not been first aid training by a agency such as American Red Cross and 3 out of 3 staff will enrolled to first aid training. ADM and LIN will submit the completed first aid training and or certification to LPA Rai once completed.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 435202828
VISIT DATE: 10/23/2023
NARRATIVE
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Page 3 of 3.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.

87411 Personnel Requirements - General is being cited during today's visit. LPA Rai would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation are observed to be not competent to provide the services necessary to meet the resident's needs.

Exit interview was conducted with Administrator Lori Mohassel and Licensee Zenebesh Ghebresellasie and they both agreed and understood the deficiencies and the Plan of Correction for each citation. A copy of this report and Appeal Rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6