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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701100
Report Date: 05/26/2022
Date Signed: 05/26/2022 02:45:12 PM


Document Has Been Signed on 05/26/2022 02:45 PM - 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 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: 5DATE:
05/26/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:TIME COMPLETED:
03:00 PM
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LPA Albert Johnson arrived unannounced at the facility and spoke with 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 observed fully charged fire extinguishers. Smoke alarms and Carbon Monoxide detector operational. Facility telephone number is (209) 939-0288.

LPA delivered PPE along with Antigen test kits.

Per California Code of Regulations, Title 22, no deficiencies were cited during this visit.

Exit interview was held.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
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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