392700690-1-21-2025-27-AS-CYAG-DCZV53-20250117150717

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700690
Report Date: 01/09/2025
Date Signed: 01/21/2025 09:12:57 AM

Document Has Been Signed on 01/21/2025 09:12 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/ DIRECTOR:	BRELIN, CLEO		FACILITY TYPE:	740
ADDRESS:	519 W SANTOS AVE		TELEPHONE:	(209) 905-4955
CITY:	RIPON	STATE: CA	ZIP CODE:	95366
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	01/09/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Mark Anthony Reyes		TIME VISIT/ INSPECTION COMPLETED:	01:30 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	Unannounced Annual visit made out to this facility on 01/09/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated representative, Mark Anthony Reyes, who was briefly interviewed at this time. Current census was 6 residents. It was learned that there were (2) residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (6) residents under the care of hospice at any given time. It was learned that this facility has a program to be able to accept and retain dementia 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 receiving services through home health at this time. Tour of this facility was conducted. Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Linen closet, located in facility hallway closet, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time. Kitchen area was toured. Kitchen drawers and cabinets were opened and reviewed. Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Pantry area was toured. Additional food storage units located in the garage area were observed to be present and functional at this time. Laundry room, located prior to the entrance for the garage, was toured. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Administrator certificate, # 6041889740, for Cleo Brelin was observed to have an expiration date of

Liza King	TELEPHONE: (650) 676-0442
Charlie Yang	TELEPHONE: (916) 709-6507
	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CLEO'S HOME	FACILITY NUMBER: 392700690
	VISIT DATE: 01/09/2025

NARRATIVE

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07/17/2026 and in compliance at this time. Forms and documents have been completed in order to renew this Administrator certificate at this time.
Medication cabinet, located in the facility kitchen cabinets, was observed to be locked and made inaccessible to the residents at this time.
First aid kit, located in the laundry room, was reviewed. This LPA observed that it did contain all of the required components at this time.
Fire extinguisher that was located in the kitchen area was observed to have been annually inspected by the local fire extinguisher company, Butch Young Fire Group, on 01/02/2025 and found to be in compliance at this time.
Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted.
A review of (4) facility personnel records was conducted on the LIC 859.
A review of (6) facility resident records was conducted on the LIC 858.

The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:

LIC 308
LIC 400
LIC 500
LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.
Appeal rights were printed and a copy was given to the facility designated representative at this 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: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/21/2025 09:12 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services

(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above in that [1} out of [6] facility residents was unable to handle, dispense, and inject themselves relying on the facility staff, at all times, in order to perform glucose testing and insulin injections which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/10/2025
	Plan of Correction
1 2 3 4	The facility designated representative stated that a plan for the resident injections will be produced to address who would be responsible for completing these tasks on a daily basis. A statement of correction, along with the updated plan of dealing with the injections, will be completed and submitted into CCL by the due date.

Section Cited

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that [3] out of [6] Medication Administration Records, with dispensing log, were not properly initialed and filled out with corresponding follow up when medications were missed, refused, or not given as prescribed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/10/2025
	Plan of Correction
1 2 3 4	The facility designated representative stated that a plan for the resident medication management will be produced to address proper handling, dispensing, and documentation of the resident medications at all times. An in-service, for no less than (1) hour in duration, will be completed for all facility staff responsible for handling, dispensing, and documentation of the resident medications. A statement of correction, along with the updated medication training, will be completed and submitted into CCL by the due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Liza King	TELEPHONE: (650) 676-0442
Charlie Yang	TELEPHONE: (916) 709-6507
	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 01/21/2025 09:12 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Infection Control Requirements

(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (B) Walls and window coverings in resident care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary and when they are visibly contaminated or soiled. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the exterior grounds needed to be clean, clear, and maintained in good repair since some of the window screens were ripped, torn, and in need of repair which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2025
	Plan of Correction
1 2 3 4	The facility designated representative stated that all window coverings and screens will be repaired/replaced to remove any rips, tears, or holes in them as well as clean up the backyard area to remove all unused furniture, dog feces, and debris. A statement of correction, along with photos of the updated screens and cleared backyard areas, will be completed and submitted into CCL by the due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Liza King	TELEPHONE: (650) 676-0442
Charlie Yang	TELEPHONE: (916) 709-6507
	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC809 (FAS) - (06/04)

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