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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701219
Report Date: 11/07/2022
Date Signed: 11/07/2022 12:42:46 PM


Document Has Been Signed on 11/07/2022 12:42 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 4FACILITY NUMBER:
392701219
ADMINISTRATOR:BRELIN, CLEO/BRELIN, JONFACILITY TYPE:
740
ADDRESS:761 HELEN DRTELEPHONE:
(408) 512-4890
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY:6CENSUS: DATE:
11/07/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Cleo BrelinTIME COMPLETED:
12:50 PM
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On 11/7/22 at 10:10 am Licensing Program Analyst (LPA) Maja Jensen arrived at facility announced to conduct a pre-licensing inspection. LPA Jensen met with Administrator Cleo Brelin and explained the purpose of today's visit.

The facility is a single story structure with one designated entrance. The entrance has a sign in table, COVID-19 precautionary signs, PPE, and a thermometer for COVID-19 Screening. The facility was observed to be sanitary and free of odor. There was adequate furniture and lighting observed throughout the facility. Night lights were observed to be installed in the hallways.

The facility has clearance for 6 residents of which 5 may be non-ambulatory and 1 may be bedridden. All doorways were of a sufficient width to accommodate a wheel chair. There are recliners available for each resident within the bedrooms. There is seating for 6 available in the living room, at the dining table and in the backyard.

The facility was stocked with sufficient linen, a 30 day supply of PPE, emergency food supply and emergency lighting. The fire extinguisher was purchased in August of 2022 and is in compliance. The carbon monoxide and fire alarm were tested and determined to be in good working order. A first aid kit was observed to be complete with manual, tweezers, scissors and various wound dressings. The emergency disaster plan was reviewed and found to be incompliance. All trash cans were observed to have tight fitting lids.

There are two bathrooms in the facility. One bathroom is located in the main hall and the other is an ensuite off of the master bedroom. The bathrooms are both equipped with grab bars at the toilet and in the shower. The shower/bath has non-slip mats available when needed. The water temperature was measured at 115 degrees and is within the required regulatory range of 105 degrees to 120 degrees Fahrenheit. Continued...

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 4
FACILITY NUMBER: 392701219
VISIT DATE: 11/07/2022
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Continued from LIC 9099...

The kitchen has a locked storage area for knives and other sharp objects making these items inaccessible to residents in care. There is a locked cabinet for medication and files available making these items inaccessible to residents in care as well. There was a 7 day supply of non-perishable food available in the pantry. A random sample of food items was checked and no expired food items were found. All appliances were observed to be in good working order. The thermostat in the facility was set for a range of between 72 and 75 degrees Fahrenheit for the comfort of residents and staff. Activities were observed to be available for clients and included, exercise videos, reading materials, bingo and other games. There is a laundry room that is kept locked and is used for storage of all cleaning supplies.

Signs were posted throughout the facility to prominently display resident rights, resident council, visiting policies, theft and loss policies and complaint reporting information. The Administrator certificate for Jon Brelin is posted at the facility and is current through 10/8/23.

The grounds were observed to be well maintained and all pathways were observed to be clear of obstruction and debris. There is a garden area available for resident use. All screens were observed to be in good repair. Ramps were installed at all exits/entrance ways.

A component III presentation was completed Cleo Brelin.

The facility was found to be in substantial compliance and has passed the pre-licensing inspection. An exit interview was conducted and a copy of this report was handed to Administrator Cleo Brelin.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC809 (FAS) - (06/04)
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