392701219-7-3-2023-27-AS-LKIG-CTXQPV-20230721122121

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392701219
Report Date: 07/03/2023
Date Signed: 07/03/2023 12:15:36 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/10/2023 and conducted by Evaluator Maja Jensen

COMPLAINT CONTROL NUMBER: 27-AS-20230410112641

FACILITY NAME:	CLEO'S HOME 4		FACILITY NUMBER:	392701219
ADMINISTRATOR:	BRELIN, JON E		FACILITY TYPE:	740
ADDRESS:	761 HELEN DR		TELEPHONE:	(408) 512-4890
CITY:	RIPON	STATE: CA	ZIP CODE:	95366
CAPACITY:	6	CENSUS: 4	DATE:	07/03/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Cleo Brelin		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility not providing adequate supervision.

INVESTIGATION FINDINGS:

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On 7/3/23 at approximately 10:10am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegation. LPA Jensen met with Licensee Cleo Brelin and explained the purpose of today's visit.

During the course of this visit LPA Jensen interviewed Licensee, staff 1 and staff 2. Licensee and 2 of 2 staff confirmed during the course of interviews that on 4/8/23 after lunch Resident 1 (R1) left the facility through the gate in the back yard without staffs knowledge. At the time of R1's departure from the facility there were staff members present. R1 was in the back yard and often spends time there. S1 was watching R1 through the back yard window and S2 was tending to other duties. S1 and S2 did not realize that R1 had exited the back yard until the neighbor knocked on the door. Staff and the Licensee all provided consistent information during the course of the interviews.

Continued on LIC 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 27-AS-20230410112641

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/03/2023

NARRATIVE

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Continued from LIC 9099...
LPA Jensen conducted a record review of R1's resident file. LPA Jensen determined that according to R1's LIC 602 (Physician's Report), R1 is unable to leave the facility unassisted.

Based on interviews conducted and records reviewed the allegation of facility not providing adequate supervision is SUBSTANTIATED. An allegation of substantiated means that the preponderance of evidence standard has been met.

Deficiencies are being cited from the Health and Safety Code (HSC). Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report was provided to Cleo Brelin.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230410112641

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/03/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/04/2023 Section Cited CCR 1569.312(e)	1 2 3 4 5 6 7	Basic services requirements Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee immediately added an adaptive device to the back gate door while still maintaining access to a fire exit so that residents are not easily able to leave the yard. No further action is required.
	8 9 10 11 12 13 14	Based on interviews conducted with 2 of 2 staff, R1 left the facility unassisted on 4/8/23 and without staff's knowledge. This poses an immediate risk to the health, safety and personal rights of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023

LIC9099 (FAS) - (06/04)

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