306004745-4-8-2025-22-AS-WVAS-DFJV94-20250408161344

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004745
Report Date: 04/08/2025
Date Signed: 04/08/2025 04:13:53 PM

Document Has Been Signed on 04/08/2025 04:13 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	LOTUS SENIOR CARE, HUNTINGTON BEACH III		FACILITY NUMBER:	306004745
ADMINISTRATOR/ DIRECTOR:	RITA LEE		FACILITY TYPE:	740
ADDRESS:	6082 KENDRICK CIRCLE		TELEPHONE:	(949) 636-8007
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92647
CAPACITY: 6		CENSUS: 5	DATE:	04/08/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	Myra Miciano		TIME VISIT/ INSPECTION COMPLETED:	04:30 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	Licensing Program Analyst (LPA) William Vanegas made an unannounced inspection for the purposes of conducting an annual inspection. Upon arrival LPA Vanegas was greeted and granted entry to the facility by Care Giver (CG) Myra Miciano and explained the purpose of the inspection. LPA Vanegas set up equipment and began a tour of the facility and observed the following. This is a two storied home with an attached two car garage. There is a total of eight bedrooms five of which are resident rooms, and three of which are staff rooms. There are four bathrooms two of which are shared, one of which is a private bathroom, and one of which is for staff use. LPA Vanegas observed kitchen area to be clean and sanitary. LPA Vanegas observed a dishwasher, refrigerator, microwave, electric stove, washer, and dryer to be in good repair and working condition. LPA Vanegas observed resident bathrooms to be clean and free of any mildew and debris. LPA Vanegas observed restrooms to have all required furnishings such as grab bars, slip resistant matts, and shower chairs. LPA Vanegas observed water faucets and toilets to be functional. Water to be between 115.2 and 117.2 degrees. LPA Vanegas observed resident rooms to have all required furnishings such as a bed, chest drawers, enough closet space for personal belongings, and clean linens in good repair meaning no strains or tears. Rooms are large enough to walk about freely, and no obstructions are blocking the entry ways. LPA Vanegas toured the outside of the facility and observed the following. There is a large backyard with an outdoor shaded sitting area. No obstructions were observed along the exit route. Side door is self latching and unlocked. CONTINUED ON LIC809C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LOTUS SENIOR CARE, HUNTINGTON BEACH III	FACILITY NUMBER: 306004745
	VISIT DATE: 04/08/2025

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LPA Vanegas reviewed medications with Care Giver (CG) Myra Miciano. Per LPA Vanegas review medications are being administered to residents in care per physicians orders. LPA Vanegas observed medications being documented correctly and in the correct order.

LPA Vanegas observed all fire extinguishers to be updated and fully charged, LPA Vanegas observed all smoke and carbon monoxide detectors to be in good repair and operational. LPA Vanegas observed first aid kit to have all required items such as adhesive tape, bandages, scissors, tweezers, and a thermometer.

LPA Vanegas reviewed five resident files, and two staff files. All files (staff and resident) had all required documents. All staff annual training was up to date and documented.

Based on observations made during today's inspection no deficiencies will be cited per tittle 22 chapter 8 division 6. An exit interview was conducted with CG Myra Miciano, and a copy of this report was left at the facility.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC809 (FAS) - (06/04)

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