Lotus of Cupertino

Type of visit: Prelicensing

Licensing Program Analysts (LPA) Manuel Monter arrived announced to conduct the pre-licensing inspection. LPA met with Applicant/ Licensee (LN) Zenebesh Ghebresellasie. The facility fire clearance is approved for 11 Non-Ambulatory residents and 1 bedridden resident. LPAs toured the facility inside and out. There are 8 resident's bedrooms on first floor. Bedrooms equipped with beds, linens and adequate lighting, furniture such as bed, dresser and chair and closet space for residents. LPA also toured the second floor of the facility, which is being used as a staff area. LPA toured the 7 first floor bathrooms and 2nd floor bathroom. The backyard was inspected. LPA observed ring cameras on the outside perimeter of the home. During tour LPA observed 1 locked shed was observed and used for storage and not for living space. LPA toured the facility Laundry room. LPA observed in the laundry room being used as a laundry room and storage space. LN confirmed the laundry room is only for laundry and storage and is not a living/sleeping space for staff or residents. There are 6 fire extinguishers in the facility. (Kitchen, in walkway between room 4 and 3, between bedroom 8 and 5, family room, stair way to the second floor, & laundry room). The facility has medication storage area, located in kitchen, for their medication and also this is where they will store residents files. The facility had a First Aid kit that was complete with tweezers and gauze and scissors. The facility is equipped with a centralized sprinkler system. Page 1 out of 2. The kitchen area was toured. Kitchen utensils observed such as but not limited to cups, plates. kitchen appliances were observed with microwave and a refrigerator. The refrigerator temperature maintained at 36 degrees Fahrenheit. Freezer temperature maintained at 0 degrees Fahrenheit. The knives and sharp objects were observed locked and inaccessible to residents in care. The facility has a working land line. The facility has window screens in all sliding doors and windows, The facility has a washer and dryer. The laundry was observed with a lock where the larger supplies of toxics and cleaning supplies are kept. The daily cleaning supplies are kept in a locked kitchen cabinet. The water temperature range for facility bathrooms ranged from 114-118 degrees F. Component III orientation was completed with Licensee. No issues noted during this pre-licensing inspection. LPAs observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required. This report was reviewed with Licensee Zenebesh Ghebresellasie and a copy of the report was provided. Page 2 Out of 2. END OF REPORT.the state’s words, verbatim · CDSS document, Sep 3, 2025

Type of visit: Office

Facility Type: Residential Care Facility for the Elderly Application Type: Initial Capacity: 12 Census (if any clients in care): 0 COMP II Participants: ZENEBESH GHEBRESELLASIE Interview Method: Telephone interview On August 13, 2025, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Aug 13, 2025