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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701219
Report Date: 02/27/2023
Date Signed: 02/27/2023 11:46:36 AM


Document Has Been Signed on 02/27/2023 11:46 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:CLEO'S HOME 4FACILITY NUMBER:
392701219
ADMINISTRATOR:BRELIN, JON EFACILITY TYPE:
740
ADDRESS:761 HELEN DRTELEPHONE:
(408) 512-4890
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY:6CENSUS: 3DATE:
02/27/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Cleo BrelinTIME COMPLETED:
12:00 PM
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On 2/27/23 at approximately 10:15am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a post licensing visit. LPA Jensen met with Cleo Brelin and explained the purpose of today's visit.

The grounds were observed to be well maintained and all paths were free of obstruction. The facility was observed to be sanitary and free of odor. There was adequate furniture throughout the home in the backyard for resident use. LPA Jensen observed night lights in the hallway. The carbon monoxide detector and smoke detector was determined to be in good working order. The first aid kit was observed to be complete with scissors, tweezers, thermometer, manual and various wound dressings. The fire extinguisher was purchased within the last 12 months and is in compliance. The facility maintains a generator and food supply for emergency use. There is a 30 day supply of PPE on hand.

The facility was observed to maintain a 2 day supply of perishable food and 7 day supply of non-perishable food. The staff was preparing beef enchilada, salad and mango juice, coffee, and Jello filled with fruit. There is an adequate linen supply on hand. All required signs were observed to be posted in prominent areas for easy viewing by residents and visitors.

LPA Jensen interacted with 3 of 3 residents who all stated they are happy in the home and well cared for. LPA Jensen reviewed 3 of 3 resident files and found them to be complete. LPA Jensen observed staff to have criminal background clearance and be associated to the facility. LPA Jensen reviewed 1 staff file and found it to be incompliance.

The facility was determined to be in substantial compliance. The Post-Licensing Inspection tool was used during the course of this visit. AN exit interview was conducted and a copy of this report was given to Licensee.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023
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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