342701429-10-16-2025-27-AS-APAA-DMHUL2-20251016153958

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701429
Report Date: 10/16/2025
Date Signed: 10/16/2025 03:40:12 PM

Document Has Been Signed on 10/16/2025 03:40 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, ARABELLA		FACILITY TYPE:	735
ADDRESS:	705 POPCORN ST.		TELEPHONE:	(916) 509-0647
CITY:	GALT	STATE: CA	ZIP CODE:	95632
CAPACITY: 4		CENSUS: 3	DATE:	10/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:30 AM
MET WITH:	Arabella Mathis		TIME VISIT/ INSPECTION COMPLETED:	12:30 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	On 10/16/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA Pascua was greeted by Facility Designated Adminsitrator (FDA), Arabella Mathis and explained the purpose of the visit. The purpose of this visit was to conduct an annual visit. There were two other staff members present at the time of this visit, Michael Joshua Doromal and Mary Joy Geron. Current census was 3. 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 hold and accept Level 4 Residents from Alta Regional Center. LPA reviewed 3 resident files and 3 staff files. It was learned that 1 out 3 staff member present was not associated to this facility. LPA Pascua provided guidance at the time of the visit to assist the facility in associating S1. In addition, additional technical assistance was provided to this facility regarding resident and staff files. The facility administrator has an active administrator certificate #7029940735 and expires on 09/09/2027. All resident files and all staff files were complete and up to date at this time. LPA Pascua initiated a tour of the facility with FDA, Arabella Mathis. One fire extinguisher was placed in the kitchen and was serviced by River City Equipment Company on 6/6/2025. Smoke detectors and carbon monoxide detectors were located throughout the facility and were observed to be functional and in compliance at this time.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LOURDES TLC, INC.	FACILITY NUMBER: 342701429
	VISIT DATE: 10/16/2025

NARRATIVE

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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.
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.
A locked medication cabinet was located in the hallway. Along with staff responsible for medication administration, the LPA reviewed and compared medication with medication administration records. A first aid kit was also identified at this time and obtained all the required components.
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.
The following documents were requested to be updated by the department:
-LIC 308
-LIC 400
-LIC 500
-LIC 610e.

There were no deficiencies observed during the course of this annual visit.
LPA provided information regarding the Technical Support Program.
An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025

LIC809 (FAS) - (06/04)

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