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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202828
Report Date: 09/27/2024
Date Signed: 09/27/2024 04:22:53 PM


Document Has Been Signed on 09/27/2024 04:22 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: 6DATE:
09/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Administrator, Lori MohasselTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Simi Rai and Santino Fortes conducted an unannounced annual inspection, and met with Administrator (ADM) Lori Mohassel. LPAs observed 3 staff and 6 residents at the facility. ADM stated there were 0 residents under Hospice services.

LPAs toured the facility inside and out including: kitchen, living room, family room and 1 staff room, 6 resident rooms and 2 restrooms.

LPAs observed 6 out of 6 exit doors in the resident rooms had secondary locks on the doors and was not kept free of obstruction wherein the door was not able to open without staff opening the locks with key. LPAs observed locked stoppers on the sliding door railings which restricted the sliding doors from opening. Staff had access to the keys to unlock door stoppers and secondary locks and were able to unlock all the doors during the visit. Licensee and ADM understood to keep all doors free of obstruction.

LPAs observed 1 out of 6 beds had attached full bed rail in R1's room. Licensee and administrator stated that R1 was not receiving hospice services. Licensee and ADM will work with R1's primary care physician to obtain written order to use 1/2 bed rail for mobility.

Restrooms observed to have non-skid flooring. LPAs observed perishable food supply of at least two days and non-perishable food supply of at least seven days. Refrigerator temperature was observed at 32 degrees F and Freezer temperature was 0 Degrees F. The front yard and backyard of the facility was also inspected. LPA observed one exit fence leading out of the facility was held up with a plank of wood. ADM stated they will repair the fence is not able to close properly. No outside storage shed was observed. LPA observed Facility License and Resident Personal rights were posted.

Continuation on LIC 809-C, page 1 of 2.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Santino FortesTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
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 3


Document Has Been Signed on 09/27/2024 04:22 PM - 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: 09/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2024
Section Cited
CCR
87307(d)(6)

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87307(d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
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ADM stated to submit a written plan of action understanding regulation and ensure all exits are kept from of obstruction by POC due date. Licensee and ADM agreed and understood.
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Based on observation and interview, 6 out of 6 exit doors located in the resident rooms had secondary locks which prohibited the door from opening which poses/posed an immediate health, safety or personal rights risk to persons in care.
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Type A
09/28/2024
Section Cited
CCR87608(a)(5)(B)

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87608(a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement is not met as evidenced by
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ADM stated to submit a written plan of action understanding regulation and ADM stated that she will contact R1's PCP for written orders for half bed rails for mobility by POC due date. Licensee and ADM agreed and understood.
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Based on observation, interview, and record review, R1 had full bed rails attached to the bed and R1 was not receiving hospice services which poses/posed an immediate health, safety or personal rights risk to persons in care.
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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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Santino FortesTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: 09/27/2024
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Page 2 of 2.

LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to clients in care. Room temperature was at 74.5 degree F, and hot water temperature was measured from resident bathroom at 119.1 degrees F. LPA inspected the facility first aid kit and it was observed to be complete. The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested. Fire extinguishers were last serviced on 9/20/24. The facility conducted their last fire drill on 8/1/24.



LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 residents medications and centrally stored medication records.

Deficiencies were cited during today's visit as per California Code of Regulations Title 22., see LIC809-D Exit interview was conducted with Lori Mohassel (ADM). This report was reviewed and a copy was provided to ADM for signature. Appeal rights were provided.

SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Santino FortesTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3