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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701429
Report Date: 12/04/2024
Date Signed: 12/04/2024 12:24:37 PM

Document Has Been Signed on 12/04/2024 12:24 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
12/04/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Arabella Mathis TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 12/04/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived announced to this facility to conduct a Pre-Licensing visit. LPA met with applicant, Arabella Mathis and explained the purpose of the visit. The purpose of this visit was to conduct a pre-licensing visit.
Current census was 0. A brief interview with applicant Mathis was conducted.

This facility will hold 3 ambulatory residents in bedrooms #1, #2, and #4 with one non-ambulatory resident in bedroom #3 with a direct exit. This facility also plans to hold and accept Level 4C level Residents from Alta Regional Center.
LPA Pascua initiated a tour of the facility with Applicant, Arabella Mathis. The applicant has an active adult residential administrator certificate #6065286735 and expires on 09/08/2025.

One fire extinguisher was placed in the kitchen and was serviced by River City Equipment Company on 06/21/2024. Smoke detectors and carbon monoxide detectors were located throughout the facility and were observed to be functional and in compliance at this time.
All rooms designated as activity areas and common areas for resident use were toured. Furniture and furnishings were observed to be present and sufficient to meet the needs of the residents at this time.
Office rooms and other areas intended for resident use were toured.
Kitchen area was toured. Facility freezer and refrigerator units were toured. LPA reviewed the food storage supply to make sure that there was always a 2-day perishable and 7-day nonperishable food quantities on site at all times. Knives were observed to be locked and made inaccessible. An additional pantry was identified to store additional non-perishable food supplies.
Storage area for chemicals and cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
A tour of 4 resident bedrooms was conducted. Furniture and furnishings were observed to sufficient and able to meet the needs of the residents at this time. Bedroom #3 was observed to have a direct exit to the back yard.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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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: LOURDES TLC, INC.
FACILITY NUMBER: 342701429
VISIT DATE: 12/04/2024
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A review 2 resident restrooms was conducted. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. Grab bars were present and functional.
A tour of the laundry room was conducted. LPA observed toxins and laundry detergent locked and made inaccessible.

This facility will be using a locked medication cabinet located in the hallway. A first aid kit was observed to be present and contained all the required components. LPA observed the medication cabinet to be locked and made inaccessible at this time. Resident files and staff files will also be stored in this storage area.

A tour of the garage was conducted. An additional refrigerator was located and will house additional perishable food supply. A locked storage unit was identified with cleaning supplies and toxins.

Exterior grounds of this facility was toured. Perimeter fence and gates were observed to be functional and in good repair at this time. This facility has two gate exits and were observed to be function.

This facility has been observed to be in compliance at this time. Based on the observations made during this visit, this applicant has passed the pre-licensing inspection.
Component III was reviewed with this applicant.

There were no deficiencies observed during the course of this Pre-Licensing visit.

An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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