392700690-1-18-2023-27-AS-MJEN-CN7PBS-20230118101048

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700690
Report Date: 01/17/2023
Date Signed: 01/18/2023 10:11:43 AM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/18/2023 10:11 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		FACILITY NUMBER:	392700690
ADMINISTRATOR:	BRELIN, CLEO		FACILITY TYPE:	740
ADDRESS:	519 W SANTOS AVE		TELEPHONE:	(209) 905-4955
CITY:	RIPON	STATE: CA	ZIP CODE:	95366
CAPACITY:	6	CENSUS: 5	DATE:	01/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Cleo Brelin		TIME COMPLETED:	05:00 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 1/17/23 at approximately 3:25pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year visit. LPA Jensen met with Licensee/Administrator Cleo Brelin and explained the purpose of today's visit. Cleo has an active Administrator's certificate good through 7/17/2024. LPA Jensen toured the facility including but not limited to the grounds, kitchen, dining room, family room, recreation room, resident bedrooms, staff room, and laundry room. The facility is a single story structure with 6 bedrooms and a swimming pool on the premises. The swimming pool is gated and the gate was determined to be locked. The grounds were observed to be well maintained and free of debris and obstruction. The facility was observed to be sanitary and free of odor. The facility smoke detectors and carbon monoxide detectors were observed to be in good working order. The facility conducts fire drills and the last fire drill was conducted in October of 2022. The fire extinguishers were last serviced in January of 2023 and are in compliance. The fist aid kit was observed to be complete with scissors, tweezers, thermometer, manual and various wound dressings. There were night lights observed in the hallways. The bathrooms were equipped with grab bars in the showers and near the toilets. The showers had non-slip mats available. Knives and medications were observed to be locked and inaccessible to residents in care. The facility was observed to maintain an adequate supply of linens and bedding. The bedrooms are equipped with night stands, chairs, dresser and lamps. The kitchen was observed to have a 2 day supply of perishable food and a 7 day supply of non-perishable food. Dinner service was observed and included chicken, noodles, vegetables, cake and fruit. Continued on LIC 809C...

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

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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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	FACILITY NUMBER: 392700690
	VISIT DATE: 01/17/2023

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Sharp objects and toxins were observed to be locked and inaccessible to residents in care. The water temperature was measured at 109 degrees which falls within the required range of 105-120 degrees. The thermostat was set at 74 degrees which falls within the required range of 68-85 degrees.

The facility was observed to have all required postings including but not limited to a 16 x 20 inch "See Something, Say Something" poster, resident rights, resident council and COVID mitigation signs. The facility had an assortment of activities for residents and schedule of worship local worship activities posted. The furniture throughout the home was found to be in good repair. The facility sketch was reviewed and found to be consistent with how the various rooms in the facility were being used. LPA Jensen measured the bathroom door ways and measured the width of 2 resident wheel chairs and determined there to be adequate clearance. LPA Jensen interacted with 3 residents during the course of the visit and reviewed 1 resident file which was found to be complete and in compliance.

LPA Jensen requested the following be sent via email to maja.jensen@dss.ca.gov by 1/24/23:

A Copy of the current liability insurance
An updated LIC 500

The facility was found to be in substantial compliance and no deficiencies were cited as a result of this visit.

An exit interview was conducted and a copy of this report was sent to Cleo Brelin via email on 1/1/8/23 for electronic signature.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC809 (FAS) - (06/04)

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