502701579-7-31-2026-27-AS-CYAG-DWHMM5-20260731094324

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701579
Report Date: 07/30/2026
Date Signed: 07/31/2026 09:44:15 AM

Document Has Been Signed on 07/31/2026 09:44 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	LOTUS HOMES ASSISTED LIVING I		FACILITY NUMBER:	502701579
ADMINISTRATOR/ DIRECTOR:	PEREZ, OLIVIA B		FACILITY TYPE:	740
ADDRESS:	1113 VAN GOGH LANE		TELEPHONE:	(480) 658-9034
CITY:	PATTERSON	STATE: CA	ZIP CODE:	95363
CAPACITY: 6		CENSUS: 3	DATE:	07/30/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Giselle Haroornelas and Olivia Perez		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced Annual visit made out to this facility on 07/30/2026 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility staff person, Giselle Haroornelas, who was briefly interviewed at this time. This LPA requested that she go ahead and contact the facility designated Administrator to inform her that CCL was present at this time. The facility designated Administrator, Olivia Perez, arrived later to this facility while this LPA was conducting this annual visit. Current census was 3 residents. It was learned that there were (2) residents under the care of hospice at this time. It was learned that this facility does have an approved hospice waiver to be able to accept and retain up to (6) hospice residents at any given time. It was learned that there weren't any residents deemed to have the diagnosis of dementia at this time. It was learned that this facility does have a dementia program on file at this time. It was learned that there weren't any residents receiving services through home health at this time. It was learned that there weren't any residents deemed to be bedridden at this time. This facility does have an approved bedridden fire clearance to be able to accept and retain up to (1) resident at this time. Tour of the facility was conducted. A tour of the living area, dining area, and all other areas intended for resident use was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Kitchen area was toured. Cabinets and drawers were reviewed at this time. Drawers storing knives and sharps were reviewed to make sure that they were locked and made inaccessible to the residents at all times. Cabinets storing detergent and all cleaning supplies were reviewed to make sure that they were locked and made inaccessible to the residents at all times.

Liza King
Charlie Yang
	DATE: 07/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LOTUS HOMES ASSISTED LIVING I	FACILITY NUMBER: 502701579
	VISIT DATE: 07/30/2026

NARRATIVE

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Facility restrooms were toured. Grab bars and non skid mats were observed to be present and in good working order at this time.
Hot water temperatures were taken to make sure that the hot water being dispensed was within the allowed range of 105-120 degrees at all times.
A review of the facility medications for the residents was conducted. It was learned that all of the resident medications were centrally stored.
First aid kit, located in the facility medication closet located in the hallway, was reviewed. It was observed that it did contain all of the required components and was in compliance at this time.
A review of the facility food supply was conducted. A tour of the facility pantry was conducted to make sure that there was a sufficient supply of 2-day perishable and 7-day non perishable food quantities on hand at all times.
It was learned that there was an additional refrigerator being used in the garage area.
Tour of the garage area was conducted. It was observed that this space was being used to store household items and personal items for the residents in care at this time.
Laundry area was toured. It was observed that the door leading into the laundry area did have the ability to be locked at this time. This door was reviewed to make sure that it was locked to be able to store detergents and bleach so that they were inaccessible to the residents at all times.
A tour of the facility resident bedrooms was conducted. Furniture and furnishings were observed to be present and able to meet the needs of the residents at this time.
Linen closet, located in the facility hallway, was reviewed.
Administrator certificate for Olivia Perez was observed to be present with certification #6071401740 set to expire on 07/10/2026.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gate, and all other exits was conducted.
A review of (3) facility resident files was conducted and noted on the following LIC 858.
A review of (3) facility staff files was conducted and noted on the following LIC 859.

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.
Exit Interview

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 07/31/2026 09:44 AM - It Cannot Be Edited

Created By: Charlie Yang On 07/30/2026 at 12:58 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LOTUS HOMES ASSISTED LIVING I	FACILITY NUMBER: 502701579
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the hot water being dispensed from a resident restroom faucet was measured at 127.6 degrees which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/31/2026
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that the hot water temperature will be maintained between 105-120 degrees at all times. A statement of correction, along with proof of 72 hours of temperature measurements taken, to be completed and submitted into CCL by the due date for review by this LPA.

Type A

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [2] out of [3] facility staff persons did not have updated first aid training which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/31/2026
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that an audit of all facility staff files will be conducted to make sure that they are complete and contain all of the required forms and documents at all times. A statement of correction, along with proof of updated First Aid Training for all facility staff, will be completed and submitted into CCL by the due date for review by this LPA.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Liza King
NAME OF LICENSING PROGRAM MANAGER:

	Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/30/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

LIC809 (FAS) - (06/04)

Page: 4 of 7

Document Has Been Signed on 07/31/2026 09:44 AM - It Cannot Be Edited

Created By: Charlie Yang On 07/30/2026 at 12:58 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LOTUS HOMES ASSISTED LIVING I	FACILITY NUMBER: 502701579
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Type A

Section Cited

CCR

87555(b)(26)

(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that there was not a sufficient supply of non perishable food items to meet the 7-day quantity requirement at all times which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/31/2026
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that this facility will maintain the required food supply quantities to be on hand at all times. A statement of correction, along with receipt of additional non perishable food items purchased, will be completed and submitted into CCL by the due date for review by this LPA.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Liza King
NAME OF LICENSING PROGRAM MANAGER:

	Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/30/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

LIC809 (FAS) - (06/04)

Page: 5 of 7

Document Has Been Signed on 07/31/2026 09:44 AM - It Cannot Be Edited

Created By: Charlie Yang On 07/30/2026 at 12:58 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LOTUS HOMES ASSISTED LIVING I	FACILITY NUMBER: 502701579
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that the Medication Administration Record, with dispensing log in use at this time, were missing staff initials and reasons for medications that were either missed, refused, or not given on these documents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/06/2026
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that Medication Administration Record, and dispensing log in use, will be audited to make sure that they are properly documented and maintained to show proper dispensing of the medications to the residents at all times. A statement of correction, along with documented proof of training for no less than (1) hour in duration on the topic of medication handling, dispensing, and proper documentation for all facility staff to be submitted into CCL by the due date for review by this LPA.

Type A

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [1] out of [3] facility resident files did not have a complete and updated medical assessment which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/31/2026
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all facility resident files will be audited to make sure that they are complete and contain all of the required forms and documents at all times. A statement of correction, along with a copy of the updated medical assessment, will be completed and submitted into CCL by the due date for review by this LPA.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Liza King
NAME OF LICENSING PROGRAM MANAGER:

	Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/30/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

LIC809 (FAS) - (06/04)

Page: 6 of 7

Document Has Been Signed on 07/31/2026 09:44 AM - It Cannot Be Edited

Created By: Charlie Yang On 07/30/2026 at 12:58 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LOTUS HOMES ASSISTED LIVING I	FACILITY NUMBER: 502701579
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that there were window screens that had holes, rips, and tears in them as well as not being present behind the window which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/06/2026
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that a review of all facility windows and window screens will be conducted to make sure that they are in good working order at all times without holes, rips, or tears in them. A statement of correction, along with receipts of services rendered for the repair/replacement of the window screens, will be completed and submitted into CCL by the due date for review by this LPA.

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [3] out of [3] facility personnel records were incomplete missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/06/2026
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that an audit of all facility personnel files will be conducted to make sure that they are updated and complete to contain all required forms and documents at all times. A statement of correction, along with copies of the updated and complete personnel files, will be completed and submitted into CCL by the due date for review by this LPA.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Liza King
NAME OF LICENSING PROGRAM MANAGER:

	Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/30/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

LIC809 (FAS) - (06/04)

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