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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701351
Report Date: 03/20/2024
Date Signed: 03/20/2024 12:33:16 PM


Document Has Been Signed on 03/20/2024 12:33 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:CELY'S CARE HOME LLCFACILITY NUMBER:
392701351
ADMINISTRATOR:BRELIN, CLEOFACILITY TYPE:
740
ADDRESS:2372 BLUE TEES DRIVETELEPHONE:
(209) 986-4632
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 0DATE:
03/20/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Cecelia Valerio ReyesTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Michael Bilger conducted an announced pre-licensing visit to this facility on 3/20/2024 at 10:15am and was met by the Applicant Cecelia Valerio Reyes, and Administrator Maria Cleotilde Brelin. Brief interview was conducted with the Applicant.
It was learned that this facility will be licensed as an Residential Care Facility for the Elderly (RCFE) to serve up to 0 ambulatory clients, 5 non-ambulatory clients, and 1 bedridden. There were no clients present during today's pre-licensing visit. Tour of the facility was conducted.
Dining area, living area, and all other areas intended for resident use were toured and observed to be furnished and maintained in compliance at this time. Exit signs in place as appropriate. Fire extinguisher in place at kitchen area and fully charged. Facility map indicating emergency exits posted in appropriate locations. Complaint poster and Ombudsman Poster observed.
Kitchen area was toured. Cabinets and drawers were opened and reviewed by this LPA along with the Applicant.
Food supply for 2-day perishable and 7-day nonperishable quantities were reviewed to make sure that this facility was in compliance at this time.
Medication cabinet, located in the hallway, was observed to locked and secure. First aid kit was observed to be present and contained all required components at this time.
A tour of the resident bedrooms was conducted. Furnishings and furniture intended for use by the clients were observed to be sufficient and able to meet the needs of the clients at this time.
A tour of the resident bathrooms was conducted. Hot water temperatures were taken and measured within the allowed range of 105-120 degrees.
Linen closet, located in the hallway, was observed to contain a sufficient supply of towels and linens able to meet the needs of the residents at this time.
{Cont. on 809C}
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CELY'S CARE HOME LLC
FACILITY NUMBER: 392701351
VISIT DATE: 03/20/2024
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A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time.

This facility has been found to be in compliance at this time. There were no deficiencies observed during today's Pre-licensing visit. Component III completed with applicant during visit. Exit Interview conducted with applicant Cecilia Valerio Reyes. A copy of this report was left with the Applicant.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC809 (FAS) - (06/04)
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