502701585-8-18-2025-27-AS-ELIM-DKNUHT-20250818153627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701585
Report Date: 08/18/2025
Date Signed: 08/18/2025 03:36:36 PM

Document Has Been Signed on 08/18/2025 03:36 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:	LORILIE'S HOME LLC		FACILITY NUMBER:	502701585
ADMINISTRATOR/ DIRECTOR:	MANALOTO, JONATHAN		FACILITY TYPE:	740
ADDRESS:	3909 FELTON WAY		TELEPHONE:	(209) 422-6505
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY: 6		CENSUS:	DATE:	08/18/2025
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Jonathan Manalto, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:40 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 08/18/2025 at 1:15 PM, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility for an unannounced post-licensing inspection. The LPA was greeted by a Caregiver. The LPA introduced herself, explained the purpose of the visit, and asked to speak to the Designated Facility Administrator. The Caregiver called the DFA, who arrived at the facility at 1:40 PM. The DFA accompanied the LPA on a tour of the facility. This facility is a three-bedroom residential house that has been cleared for six non-ambulatory residents by the City of Modesto Regional Fire Authority on 01/06/2025. The census at the time of this site inspection was four. The LPA toured the living room, dining room, kitchen, bedrooms, and bathrooms. The LPA observed that the entire facility was clean, odor-free, and pest-free. Each bedroom had the required furniture in it. The bathrooms had grab bars and non-slip surfaces. The water temperature at a bathroom sink was 105 degrees Fahrenheit. The temperature displayed on the thermostat was 76 degrees Fahrenheit. The hallway closet contained extra linens. The living and dining rooms contained enough seating for all residents. The DFA tested the smoke and carbon monoxide detectors and an alarm sounded on the interconnected system. The LPA inspected the fire extinguisher, which was last serviced on 12/20/2024 by Jorgensen Co. (Continued on LIC 809-C.)

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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)

Page: 2 of 3

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: LORILIE'S HOME LLC	FACILITY NUMBER: 502701585
	VISIT DATE: 08/18/2025

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
26
27
28
29
30
31
32

The LPA toured the kitchen, garage, and laundry room. In the kitchen, the LPA observed that sharps were locked in a kitchen drawer. The facility had a 2-day supply of perishable food and a 7-day supply of non-perishable food in the kitchen cabinets and refrigerator-freezer. The kitchen trash can had a lid on it. In the laundry room, the LPA observed a locked cabinet that contained disinfectants and cleaners. In the garage, which was locked and inaccessible to residents, the LPA observed another refrigerator-freezer with additional food, storage cabinets, and a locked cabinet with more cleaners.

The LPA toured the backyard, which had a shaded seating area and concrete walkways that were free of obstructions.

The LPA inspected the central medication storage. Each resident's medication was stored in a separate container, and each resident's medication bottles were original with intact labels. The LPA inspected the medications and paper-based Medication Administration Record (MAR) for two residents, and found that they matched.

The LPA conducted a review of records for two staff and two residents, and found them to be well-organized and complete. Both caregivers on duty had criminal background clearances and current CPR/First Aid certifications.

As a result of this inspection, the facility was in compliance with California Code of Regulations (CCR), Title 22, Division 6. Post-Licensing is complete and this facility has no deficiencies.

An exit interview was conducted with the licensee, to whom a copy of this LIC809 report was provided. Their signature below confirms receipt of this document.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3