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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701355
Report Date: 05/02/2024
Date Signed: 05/08/2024 09:46:33 AM

Document Has Been Signed on 05/08/2024 09:46 AM - 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 3FACILITY NUMBER:
392701355
ADMINISTRATOR/
DIRECTOR:		BRELIN, CLEOFACILITY TYPE:
740
ADDRESS:1662 DEDINI LNTELEPHONE:
(408) 512-4890
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY: 6CENSUS: 3DATE:
05/02/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Cleo BrelinTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Unannounced Post Licensing visit made out to this facility on 05/02/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Cleo Brelin, at this time. A brief interview was conducted with the facility designated Administrator at this time.
It was learned that this facility was licensed to accept and retain up to 6 non ambulatory residents at any given time. This facility also has a fire clearance for (1) bedridden resident and an approved hospice waiver for (6) residents.
Current census was 3 residents.
Tour of this facility was conducted.
A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were observed to be locked and made inaccessible to the residents at this time.
Cleaning agents, bleach, and other supplies were observed to be locked and made inaccessible to the residents at this time.
A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times.
Medication cabinet, located in the kitchen area, was reviewed. Policies and procedures involving handling, dispensing, and documentation of the resident medications were discussed with the facility designated Administrator at this time. A review of the facility Medication Administration Record and dispensing log was conducted.
Medication cabinet was observed to be locked and made inaccessible to the residents at this time.
Living room, dining area, and all other areas intended for resident use were observed to furnished and maintained in compliance at this time and able to meet the needs of the residents.
A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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 3
FACILITY NUMBER: 392701355
VISIT DATE: 05/02/2024
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A tour of the resident restrooms was conducted.
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 measured within the allowed range of 105-120 degrees at all times.
Laundry area was toured. Cleaning supplies, detergents, and bleach were observed to be present and made inaccessible to the residents at this time.
Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the garage area was conducted.
First aid kits were observed to be present and contained all of the required components at this time.
Fire extinguisher was observed to be placed in the kitchen area and was just recently purchased and found to be in compliance at this time.
A tour of the exterior grounds for this facility was conducted. A review of the facility perimeter fence, side gates, and exits was conducted.

A review of (3) facility resident files was conducted and noted on the following LIC 858.
A review of (3) facility staff files was conducted and noted on the following LIC 859.

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/08/2024 09:46 AM - It Cannot Be Edited


Created By: Charlie Yang On 05/02/2024 at 04:32 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CLEO'S HOME 3
FACILITY NUMBER: 392701355

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the resident medications were pre-poured in advance in smaller separate containers for 24 hours which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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The facility designated Administrator stated that all facility staff handling, dispensing, and documenting facility resident medications will be trained, for no less than (1) hour in duration, on the topic of maintaining all resident medications in their original containers and not pre-pour in advance. A statement of correction, along with proof of updated medication training, will be completed and submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
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