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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700420
Report Date: 03/28/2022
Date Signed: 03/28/2022 01:30:40 PM


Document Has Been Signed on 03/28/2022 01:30 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:CLEO'S HOME 2FACILITY NUMBER:
392700420
ADMINISTRATOR:BRELIN, MARIA CLEOTILDEFACILITY TYPE:
740
ADDRESS:2426 W ALPINE AVETELEPHONE:
(408) 512-4890
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:6CENSUS: 5DATE:
03/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Maria Cleotilde BrelinTIME COMPLETED:
01:35 PM
NARRATIVE
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On 3/28/22 at 9:52am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit. LPA met with Administrator Maria Cleotilde Brelin and explained the purpose of the visit. LPA requested medication logs, physician orders for resident1 (R1), R2 and R3. LPA also reviewed incident report dated 2-22-22 for R1. LPA also conducted a facility observation. LPA also interviewed Administrator. Additionally, LPA reviewed Admission agreements for R1, R2, and R3.

LPA toured facility inside and out. Current temperature is 68*f. Facility appears clean and sanitary with no foul odors. LPA was screened for COVID upon entry including temperature and COVID-19 screening questions. All toxins and other dangerous materials are secured and inaccessible to residents in care. Food supply is adequate and meets the 7 days non-persishable and 2 days perishable items requirement. No obstructions to fire exits noted. LPA conducted COVID-19 screening questions prior to entry to ensure no active COVID at this time. Bathrooms appeared clean and sanitary. COVID signage observed. Hand sanitizer observed throughout. Based on facility observation, it was determined that R1 is currently on isolation for skin condition. LPA did not observe isolation cart or signage on R1s door to indicate isolation precautions. Based on review of medication logs and medication orders, it was determined that a medication order for a skin condition originated on 3/18/22 and was not started for R1 until 3/25/22 and alternative methods were not initiated by licensee to ensure skin treatment for R1 was received. A review of admission agreements for R1, R2, and R3 as well as interview with Administrator revealed a notification of rate increase was given which did not reflect a 60-day notice of rate increase.

Based on record reviews, observations, and interviews, deficiencies are cited under Title 22, Division 6 and Health and Safety Codes. An exit interview was conducted with Maria Cleotilde Brelin and a copy of this report was given to Maria. Appeal rights provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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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Document Has Been Signed on 03/28/2022 01:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: CLEO'S HOME 2
FACILITY NUMBER: 392700420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2022
Section Cited

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Incidental Medical and Dental Care. (a)A plan for incidental medical and dental care shall be developed by each facility..(1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.This requirement is not met as evidenced by:
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Based on record review and interview, Licensee did not ensure R1 receive treatment for a skin condition. Medication was ordered 3/18/22 and R1 did not receive medication from facility staff until 3/25/22 due to insurance issues. Alternative steps were not taken to ensure treatment received by R1. This poses an immediate health and safety risk to residents in care.
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LPA to submit a signed declaration of understanding Section 87465 to LPA by POC due date.
Type A
03/29/2022
Section Cited

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Personal Rights. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
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Based on LPA observation, Licensee did not ensure isolation room contained appropriate precautions including signage and isolation cart to promote safe and healthful accommodations. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/28/2022 01:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: CLEO'S HOME 2
FACILITY NUMBER: 392700420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2022
Section Cited

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1569.655. Increase in fee rates for elderly residents...(a)If a licensee of a residential care facility for the elderly increases the rates of fees for residents...the licensee shall provide no less than 60 days' prior written notice to the residents or the resident representatives...setting forth the amount of the increase...
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This requirement is not met as evidenced by: Based on interview and record review, licensee did not ensure regulatory requirements for a 60-day notice given to R1, R2, and R3 for a general rate increase. This poses a potential health, safety, and resident rights risk to residents in care.
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Licensee will read regulation 1569.655(a) and submit a signed declaration of understanding to LPA by POC due date.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
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