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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700420
Report Date: 10/12/2023
Date Signed: 10/12/2023 09:56:09 AM


Document Has Been Signed on 10/12/2023 09:56 AM - 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: 2DATE:
10/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Dominic Maata - AdministratorTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA met with the administrator and explained the purpose of the visit.

LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. There are seven bedrooms total in this facility. Five bedrooms are for residents, one room is for staff, and another room is for medication storage only. No obstructions to fire exits noted. There is a locked gated area for gardening supplies not accessible to residents. Facility has a separate living room and family room with dining area off the kitchen.

The facility submitted a LIC 808 mitigation plan, which was approved. Water temperature reads 110.9*F in the kitchen sink which meets the 105-120 degree Fahrenheit regulation. and room temperature reads 74*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers were last inspected on 1/11/2022. Facility has an emergency food and water kit.

LPA reviewed three staff and two resident files that were locked and readily available for review. Staff had current First Aid/CPR certificates All staff have criminal record clearance and are associated to the facility.

LPA received the following updated documents on today's date: LIC 308 Designation of Responsibility and copy of liability insurance.

Per the California Code of Regulations, Title 22 no deficiencies were observed or cited. 

Exit interview held with Administrator. A report and LIC 811 (Confidential Names) was left at the facility
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
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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