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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700690
Report Date: 01/17/2025
Date Signed: 01/21/2025 09:13:20 AM

Document Has Been Signed on 01/21/2025 09:13 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 HOMEFACILITY NUMBER:
392700690
ADMINISTRATOR/
DIRECTOR:
BRELIN, CLEOFACILITY TYPE:
740
ADDRESS:519 W SANTOS AVETELEPHONE:
(209) 905-4955
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
01/17/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Cleo BrelinTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Unannounced Plan of Correction visit made out to this facility on 01/17/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA 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..
The purpose of this visit was to follow up on the deficiencies that were cited from a prior annual visit conducted on 01/09/2025. This visit was to follow up on the Plan of Correction that was due.

The following deficiencies were observed and cited on 01/09/2025:
  • 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:

  • 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.

  • 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.
Plan of Correction clearance letter was printed and a copy was provided to the facility designated Administrator at this time.

There were no further deficiencies observed or cited during today's Plan of Correction visit. Exit Interview
Liza KingTELEPHONE: (650) 676-0442
Charlie YangTELEPHONE: (916) 709-6507
DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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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