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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202828
Report Date: 12/27/2024
Date Signed: 12/27/2024 12:52:03 PM

Document Has Been Signed on 12/27/2024 12:52 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/
DIRECTOR:		MOHASSEL, LORIFACILITY TYPE:
740
ADDRESS:2119 MONROE STREETTELEPHONE:
(408) 564-7719
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Administrator (ADM) Lori MohasselTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit to follow up on the Type A deficiencies cited on 9/27/2024. LPA Rai met with Administrator (ADM) Lori Mohassel and stated the purpose of today's visit. LPA Rai observed 2 staff and 6 residents in the facility.

During visit, LPA Rai observed all outdoor and indoor passageways kept free of obstruction and all 6 exit door had removed secondary locks.

LPA Rai observed resident R1's half-bed rail and reviewed physician's order for half-bed rail for mobility in resident's file. R1 is now under Hospice services.

During visit, LPA Rai provided letter of the Deficiency Citations cleared.

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

This report was reviewed with Administrator (ADM) Lori Mohassel and a copy of the report was provided.
Romeo ManzanoTELEPHONE: (650) 388-2297
Simranjit RaiTELEPHONE: (408) 324-2112
DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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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