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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700690
Report Date: 01/26/2022
Date Signed: 01/26/2022 04:08:30 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/26/2022 04:08 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 HOMEFACILITY NUMBER:
392700690
ADMINISTRATOR:BRELIN, CLEOFACILITY TYPE:
740
ADDRESS:519 W SANTOS AVETELEPHONE:
(209) 905-4955
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY: 6CENSUS: 4DATE:
01/26/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Maria Brelin - AdministratorTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Ruth Wallace and Maja Jensen conducted an unannounced annual/random inspection on 1/26/2022. LPA's met with Administrator Maria Brelin and explained the purpose of the visit. Administrator Certificate #6041889740 expires 07/17/2022.

This facility is a single story building licensed to serve six (6) non-ambulatory residents of which 1 resident may be bed ridden and a hospice waiver for 6 residents. LPA's toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, garage and backyard area. LPA's observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed a body of water at the facility to be unlocked and unsecured with a gated fence around the pool.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at (115.2) degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguishers expire 01/20/2023. LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to residents. LPA reviewed staff associations to the facility. First aid kit was checked and is complete.

Deficiency is cited from California Code of regulations, Title 22, Division 6, 8 and citation is listed on the attached LIC 809-D. Immediate Civil Penalty Assessed of $500.00.

Exit interview held with Maria Brelin. A copy of reports, civil penalty, and appeal rights left with Administrator.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2022
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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Document Has Been Signed on 01/26/2022 04:08 PM - It Cannot Be Edited


Created By: Ruth Wallace On 01/26/2022 at 02:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CLEO'S HOME
FACILITY NUMBER: 392700690

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2022
Section Cited
CCR
87307(e)

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Personal Accommodations and Services - 87307(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools, or similar bodies of water, when not in active use by residents, through fencing, covering or other means.
This requirement is not met as evidenced by:
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Licensee agrees to lock gate to pool area immediately while LPA's are conducting 1 Year Annual Inspection. LPA;s observed gate being locked. Immediate Civil Penalty Assessed.
No further action required.
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LPA's observed pool gate unlocked to pool area. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2022


LIC809 (FAS) - (06/04)
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