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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
392700690
Report Date:
01/18/2024
Date Signed:
01/23/2024 10:06:17 AM
Document Has Been Signed on
01/23/2024 10:06 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
SACRAMENTO SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
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:
6
DATE:
01/18/2024
TYPE OF VISIT:
Post Licensing
UNANNOUNCED
TIME BEGAN:
10:00 AM
MET WITH:
Cleo Brelin
TIME COMPLETED:
11:00 AM
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Unannounced Post Licensing visit made out to this facility on 01/18/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Cleo Brelin. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 6 residents.
It was learned that there weren't any residents under the care of hospice at this time.
This facility does have a hospice waiver to be able to accept and retain up to (6) hospice residents at any given time.
It was learned that there were (2) residents diagnosed with dementia at this time.
It was learned that there were (2) residents under the care of home health at this time.
A tour of this facility was conducted.
This Post Licensing visit was conducted in conjunction with the annual visit that was also completed on this day and time.
Exit Interview
SUPERVISOR'S NAME:
Liza King
TELEPHONE:
(650) 676-0442
LICENSING EVALUATOR NAME:
Charlie Yang
TELEPHONE:
(916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE:
01/18/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/18/2024
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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