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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701100
Report Date: 12/21/2021
Date Signed: 12/24/2021 07:16:40 AM

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 3FACILITY NUMBER:
392701100
ADMINISTRATOR:BRELIN, MARIA CLEOTILDE C.FACILITY TYPE:
740
ADDRESS:2372 BLUE TEES DR.TELEPHONE:
(408) 512-4890
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 3DATE:
12/21/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Maria (Cleo) TIME COMPLETED:
11:45 AM
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LPA Albert Johnson arrived unannounced at the facility and was met by Maria.

LPA conducted a tour inside and outside the facility. LPA observed the back yard
with a secured fence. LPA observed all hallways and passageways to be free of clutter or hazards. LPA observed resident rooms and living areas to be adequately furnished.

LPA observed adequate supply of linens and first aid kits. Emergency exit and phone number are posted. LPA tested water temperature in resident bathroom at 112 degrees F. LPA observed bathroom facilities to be functioning properly. Cleaning supplies and chemicals are stored in locked cabinet. Medications and confidential paperwork will be stored in a locked cabinet. LPA completed the Component III.

Fire clearance is for six NON- AMBULATORY residents. Activity supplies available. LPA observed fully charged fire extinguishers. Smoke alarms and Carbon Monoxide detector operational. Facility telephone number is (209) 939-0288

This report will be forwarded to the centralized application unit for continued processing.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
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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