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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701429
Report Date: 11/18/2024
Date Signed: 11/18/2024 11:59:53 AM

Document Has Been Signed on 11/18/2024 11:59 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:LOURDES TLC, INC.FACILITY NUMBER:
342701429
ADMINISTRATOR/
DIRECTOR:		MATHIS, ARABELLAFACILITY TYPE:
735
ADDRESS:705 POPCORN ST.TELEPHONE:
(916) 509-0647
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 4CENSUS: 0DATE:
11/18/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Arabella Mathis, Applicant/AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:53 AM
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Component II completion: Successful

Facility Type: Adult Residential Facility (ARF)
Application Type: Initial
Capacity: 4
Census (if any clients in care): none
COMP II Participants: Arabella Mathis, Applicant/Administrator
Interview Method: Telephone interview

On November 11, 2024 at 11:00 AM, 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 that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22.

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. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview with Applicant/Administrator. Report sent via email and request to return sign copy to CAB by end of business day.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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