392701440-8-27-2024-27-AS-CYAG-D8JTT4-20240827150007

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701440
Report Date: 08/21/2024
Date Signed: 08/27/2024 03:00:12 PM

Document Has Been Signed on 08/27/2024 03:00 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:	CLEO'S HOME 2		FACILITY NUMBER:	392701440
ADMINISTRATOR:	BRELIN, MARIA CLEOTILDE		FACILITY TYPE:	740
ADDRESS:	1463 AUGUSTA POINTE DR		TELEPHONE:	(408) 512-4890
CITY:	RIPON	STATE: CA	ZIP CODE:	95366
CAPACITY:	6	CENSUS: 2	DATE:	08/21/2024
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Cleo Brelin		TIME COMPLETED:	01:00 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	Unannounced Post Licensing visit made out to this facility on 08/21/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator, Cleo Brelin, who was briefly interviewed at this time. Current census was 2 residents. It was learned that there weren't any residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (6) residents under the care of hospice at any given time. It was learned that this facility has a program to be able to accept and retain dementia residents at any given time. It was learned that there was (1) resident diagnosed with dementia at this time. It was learned that there was (1) resident receiving services through home health at this time. Tour of this facility was conducted. Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Linen closet, located in facility hallway closet, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time. Kitchen area was toured. Kitchen drawers and cabinets were opened and reviewed. Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Pantry area was toured. Additional food storage units located in the garage area were observed to be present and functional at this time. Laundry area, located in the room next to the garage, was toured. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Administrator certificate, # 7032688740, for Cleo Brelin was observed to have an expiration date of

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

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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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: CLEO'S HOME 2	FACILITY NUMBER: 392701440
	VISIT DATE: 08/21/2024

NARRATIVE

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07/17/2024 and in compliance at this time.
Medication cabinets, located in the facility living area, was observed to be locked and made inaccessible to the residents at this time.
First aid kit, located in the kitchen cabinet, was reviewed. This LPA observed that it did contain all of the required components at this time.
Fire extinguishers were located throughout this facility and observed to have been purchased at the local Costco, with the receipt with date of annual purchase attached on 04/21/2024, and in compliance at this time.
Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted.
A review of (2) facility personnel records was conducted on the LIC 859.
A review of (2) facility resident records was conducted on the LIC 858.

The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:

LIC 308
LIC 400
LIC 500
LIC 610

There were no deficiencies observed or cited during today's post licensing visit.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC809 (FAS) - (06/04)

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