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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701219
Report Date: 07/03/2023
Date Signed: 08/04/2023 07:33:40 AM


Document Has Been Signed on 08/04/2023 07:33 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: 4DATE:
07/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Cleo BrelinTIME COMPLETED:
12:30 PM
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On 7/3/23 at approximately 11:30am Licensing Program Analyst Maja Jensen arrived at facility unannounced to conduct a case management related to an incident report received for a minor outdoor fire. LPA Jensen met with Licensee Cleo Brelin and explained the purpose of today's visit.

LPA Jensen interviewed the Licensee Cleo Brelin regarding the facts surrounding the incident. On 6/14/23 the HVAC on the outside of the house next to the garage caught fire. There were 3 staff members present at that time. Upon realizing the fire had started the staff called 911 and brought all residents outside to the front of the house. The staff then called the Licensee who also arrived. Staff used the facility fire extinguisher to put out the fire. The fire department arrived after the fore was out and determined that there was no additional active threat. The fire department further determined that the cause was the air conditioner condenser unit failure. The facility property was purchased late in the fall of 2022. LPA Jensen reviewed the home inspection report. The report was written inspector badge # 18350 with Home Inspection Services at 2pm on 8/6/22 and states under section 8.3 "the AC condenser was inspected and no adverse conditions were noted." LPA determined that the facility took all necessary actions needed to ensure the safety of the residents therefore no deficiencies are being issued as a result of this case management.

An exit interview was conducted and a copy of this report was provided to Cleo Brelin.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 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.

LIC809 (FAS) - (06/04)
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