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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700420
Report Date: 11/21/2022
Date Signed: 11/21/2022 03:54:35 PM


Document Has Been Signed on 11/21/2022 03:54 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: 6DATE:
11/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Dominic MaataTIME COMPLETED:
04:00 PM
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On 11-21-22 at 2:02pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit related to an incident reported on 11-15-22. LPA met with facility manager Dominic Maata and explained the purpose of the visit. Administrator Cleotilde Maria Brelin was notified of LPA's visit and purpose, and gave permission for facility manager to sign in her absence. LPA reviewed physician orders and care notes for resident1 (R1) and R2 and conducted facility tour. LPA also interviewed facility manager.

Based on interviews and record reviews, it was determined that R1 was treated on 11-9-22 for suspicion of scabies after skin was assessed by hospice physician. A medication cream was ordered by R1's physician and R1 was isolated as a result in a private room. On 11-14-22, R2 developed rashes and was treated as a precaution with medication cream ordered by R2's physician. Both R1 and R2 have received treatments as ordered. At this time follow up appointments are scheduled for R1 and R2 to further assess skin conditions. Isolation precautions remain in place for R1 and R2 including private rooms, isolation carts with PPE and infection control signage visable. A 30-day supply of PPE observed by LPA. All staff wearing masks. LPA checked for COVID symptoms prior to entering.

As a result, of today's visit, no citations are issued. An exit interview was conducted with Dominic Maata and a copy of this report was left with Dominic.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
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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