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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701219
Report Date: 10/16/2023
Date Signed: 10/16/2023 01:27:38 PM


Document Has Been Signed on 10/16/2023 01:27 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, JON EFACILITY TYPE:
740
ADDRESS:761 HELEN DRTELEPHONE:
(408) 512-4890
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY:6CENSUS: 5DATE:
10/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Cleo Brelin - AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA met with the administrator and explained the purpose of the visit.

LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. There are four bedrooms total in this facility. No obstructions to fire exits noted. Facility has a separate living room and family room with dining area off the kitchen.

The facility submitted a LIC 808 mitigation plan, which was approved. Water temperature reads 109.8*F in the kitchen sink which meets the 105-120 degree Fahrenheit regulation. and room temperature reads 75.2*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers were last inspected on May 16, 2023. Facility has an emergency food and water kit.

LPA reviewed three staff and five resident files that were locked and readily available for review. Staff had current First Aid/CPR certificates All staff have criminal record clearance and are associated to the facility.

LPA requested the following updated documents to be submitted via email by 10/23/2023: LIC 308 Designation of Responsibility and copy of liability insurance.
ruth.wallace@dss.ca.gov

Per the California Code of Regulations, Title 22 no deficiencies were observed or cited. 
Exit interview held with Administrator. A report and LIC 811 (Confidential Names) was left at the facility
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
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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