<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801828
Report Date: 03/11/2022
Date Signed: 03/11/2022 04:47:12 PM

Document Has Been Signed on 03/11/2022 04:47 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:LOTUS VILLAFACILITY NUMBER:
425801828
ADMINISTRATOR:THARANGANIE MOHOTTIGEFACILITY TYPE:
740
ADDRESS:924 VIA LOS PADRESTELEPHONE:
(805) 964-4960
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY: 6CENSUS: 5DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Tharanganie Mohottige, AdministratorTIME COMPLETED:
01:10 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) K. Kontilis conducted an unannounced Annual Inspection and Infection Control Inspection of the facility. A mitigation plan has been submitted to CCLD. LPA arrived at the facility at approximately 11:30 AM and was greeted by Staff 1 (S1). Administrator Tharanganie Mohottigue arrived at approximately 11:51 AM. LPA inspected the one-story facility for fire safety, personal accommodations, and food service.

Entrance interview conducted.
There are currently five (5) residents residing in the facility. There are no residents currently on hospice. There are two (2) ambulatory residents and three (3) non-ambulatory residents.
At the time of arrival, there were three staff available in the facility and five (5) residents present in the facility.
LPA toured the facility with Administrator. LPA observed five (5) resident bedrooms, and one (1) staff bedroom. Bedrooms #1, 2, and 4 are private rooms with private bathrooms. Bedrooms 3 and 5 are private bedrooms with a shared bathroom off the hallway.
Walls, floors, and doorways are clean with no safety hazards. The kitchen area consists of a counter top area, a refrigerator, a stove, a microwave, and a sink. Sharps and centrally stored medications are kept in a locked cabinet in the dining area with no access to residents. First aid kit was observed to be complete. Fire inspection was current.
There is a sufficient amount of perishables for seven (7) days and non-perishables for two (2) days. Emergency food is stored in a second refrigerator and pantry located in the garage. There is a washing machine and a clothes dryer in the garage. Chemicals and toxic substances are kept in a locked cabinet under the kitchen sink.
There is one carbon monoxide alarm and eight smoke alarms.
Please continue to 809-C, Pg 2.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LOTUS VILLA
FACILITY NUMBER: 425801828
VISIT DATE: 03/11/2022
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
26
27
28
29
30
31
32
 The living room and dining area are neat and clean. The facility maintains a comfortable temperature. Hallways, bedroom doors and walls are in good repair.
A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights, Ombudsman contact, and Resident’s Rights. Caregiver duties and responsibilities are posted in the kitchen area.
Residents may participate at will in activities such as personal care appointments, medical appointments, games, exercising, neighborhood walks, sitting on the patio, outdoor excursions to parks, beaches, and shopping at local retail businesses.
The backyard consists of pebble embedded ramps, a picnic table, and fruit trees in a shaded area. The recycling bin, green waste bin, and trash bins are standard bins with flip lids.

Exit interview conducted. No deficiencies noted. No citations issued. Copy of report issued via email.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2