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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701293
Report Date: 08/07/2023
Date Signed: 08/07/2023 01:06:02 PM

Document Has Been Signed on 08/07/2023 01:06 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:LORILIE'S CARING HEARTFACILITY NUMBER:
502701293
ADMINISTRATOR:MANALOTOFACILITY TYPE:
740
ADDRESS:3109 WATERBURY COURTTELEPHONE:
(408) 991-5883
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 0DATE:
08/07/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jonathan ManalotoTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund arrived at the announced to conduct an pre-licensing inspection and Component III. LPA Jason Lund met with Licensee Jonathan Manaloto and explained the reason for the visit. The capacity of the facility is 6 non-ambulatory residents.

LPA Jason Lund & Licensee Jonathan Manaloto inspected/toured the physical plant: Patio is shaded with sufficient furniture. The facility and all four bedrooms are equipped with sufficient furniture and lighting. Grab bars and non-skid mats are present in bathrooms. All common areas are free of hazards, clean and in good repair. The is a storage shed that is locked. There is a room attached to the house that has a jacuzzi. It was securely locked and inaccessible to residents. There is a fire extinguisher present that was inspected on 2/1/2023. There are plenty of pots and pans to use for food preparation. Thermometers were observed in both the refrigerator as well as the freezer. The facility has centralized heating and cooling and both are operational. LPA observed locked garage. There is a sufficient seven- day non-perishable and two- day perishable food supply. LPA observed locked garage doors, a laundry area (chemicals locked in cabinet), locked drawer for knives, and sharp objects inaccessible to residents. LPA observed auditory devices installed on all exit doors, LPA observed medication storage that is locked and secured and LPA observed activities available to residents. There was a fully stocked First Aid Kit. There are two fire and carbon monoxide detectors in the home.

During today's visit, a brief presentation of Title 22, educational information with an emphasis on facility operation and commonly found problems was given to the licensee and administrator to complete Component III. An exit interview was conducted with Licensee Jonathan Manaloto and report left.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023
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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