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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700420
Report Date: 06/22/2022
Date Signed: 06/22/2022 12:33:56 PM


Document Has Been Signed on 06/22/2022 12:33 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: 4DATE:
06/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Maria CleotildeTIME COMPLETED:
01:00 PM
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On 6-22-22 at 10:20am, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management visit as a follow up for a previous visit on 3-28-22. LPA met with Administrator Maria Cleotilde Brelin and explained the purpose of the visit. LPA also interviewed Administrator, interviewed and observed Resident1 (R1). LPA also interviewed R2. LPA also reviewed facility file documentation including visitation log, and medication log books from April, May, and June of 2022 for R1 and R2. LPA also conducted a facility observation. Facility has a current census of 4. LPA toured facility inside and out. Facility was clean and sanitary with no foul odors observed. Floors and walls were clean without major defects. LPA did not observe sharp objects or toxins accessible to residents in care. Food supply was adequate to meet the 7 days of non-perishables and 2 days of perishables. Resident bedrooms were clean and sanitary, and contain all necessary furnishings. At this time, facility does not have any active COVID cases and no isolation precautions necessary at this time. Medication records were observed to be accurate at this time. LPA also requested an updated LIC 500. LPA observed care and supervision performed by staff on duty during visit to be timely. Meals were served timely.

As a result of today's visit, no deficiencies are issued. An exit interview was conducted with Maria Cleotilde Brelin and a copy of this report was left with Maria.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
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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