<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701351
Report Date: 01/23/2024
Date Signed: 03/27/2024 03:57:38 PM


Document Has Been Signed on 03/27/2024 03:57 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:CELY'S CARE HOME LLCFACILITY NUMBER:
392701351
ADMINISTRATOR:BRELIN, MARIAFACILITY TYPE:
740
ADDRESS:2372 BLUE TEES DRIVETELEPHONE:
(209) 986-4632
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: DATE:
01/23/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Cleo and Maria Brelin TIME COMPLETED:
03:56 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
COMP II by CAB successfully completed

Method: Phone Call at CAB

Census (if any clients in care):

Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:

1. Facility operation: License type, client/resident populations, and program

2. Staff qualifications and responsibilities

3. Applicant and Administrator qualifications

4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions

5. Grievances, Complaints, Community resources

6. Physical plant, food service

7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property

SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) -651-7817
LICENSING EVALUATOR NAME: Gina BaldwinTELEPHONE: (916) 651-7817
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
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 1