Cleo's Home 4

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA met with the administrator and explained the purpose of the visit. LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. There are four bedrooms total in this facility. No obstructions to fire exits noted. Facility has a separate living room and family room with dining area off the kitchen. The facility submitted a LIC 808 mitigation plan, which was approved. Water temperature reads 109.8*F in the kitchen sink which meets the 105-120 degree Fahrenheit regulation. and room temperature reads 75.2*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers were last inspected on May 16, 2023. Facility has an emergency food and water kit. LPA reviewed three staff and five resident files that were locked and readily available for review. Staff had current First Aid/CPR certificates All staff have criminal record clearance and are associated to the facility. LPA requested the following updated documents to be submitted via email by 10/23/2023: LIC 308 Designation of Responsibility and copy of liability insurance. ruth.wallace@dss.ca.gov Per the California Code of Regulations, Title 22 no deficiencies were observed or cited. Exit interview held with Administrator. A report and LIC 811 (Confidential Names) was left at the facilitythe state’s words, verbatim · CDSS document, Oct 16, 2023

Allegation investigated: Facility not providing adequate supervision.

On 7/3/23 at approximately 10:10am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegation. LPA Jensen met with Licensee Cleo Brelin and explained the purpose of today's visit. During the course of this visit LPA Jensen interviewed Licensee, staff 1 and staff 2. Licensee and 2 of 2 staff confirmed during the course of interviews that on 4/8/23 after lunch Resident 1 (R1) left the facility through the gate in the back yard without staffs knowledge. At the time of R1's departure from the facility there were staff members present. R1 was in the back yard and often spends time there. S1 was watching R1 through the back yard window and S2 was tending to other duties. S1 and S2 did not realize that R1 had exited the back yard until the neighbor knocked on the door. Staff and the Licensee all provided consistent information during the course of the interviews. Continued on LIC 9099C... Substantiated Continued from LIC 9099... LPA Jensen conducted a record review of R1's resident file. LPA Jensen determined that according to R1's LIC 602 (Physician's Report), R1 is unable to leave the facility unassisted. Based on interviews conducted and records reviewed the allegation of facility not providing adequate supervision is SUBSTANTIATED. An allegation of substantiated means that the preponderance of evidence standard has been met. Deficiencies are being cited from the Health and Safety Code (HSC). Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report was provided to Cleo Brelin.the state’s words, verbatim · CDSS document, Jul 3, 2023 · control 27-AS-20230410112641

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1569.312(e) · Plan of correction due date: Jul 4, 2023

Basic services requirements Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement was not met as evidenced by: Based on interviews conducted with 2 of 2 staff, R1 left the facility unassisted on 4/8/23 and without staff's knowledge. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jul 3, 2023

Plan of correction: Licensee immediately added an adaptive device to the back gate door while still maintaining access to a fire exit so that residents are not easily able to leave the yard. No further action is required.

Type of visit: Case Management - Incident

On 7/3/23 at approximately 11:30am Licensing Program Analyst Maja Jensen arrived at facility unannounced to conduct a case management related to an incident report received for a minor outdoor fire. LPA Jensen met with Licensee Cleo Brelin and explained the purpose of today's visit. LPA Jensen interviewed the Licensee Cleo Brelin regarding the facts surrounding the incident. On 6/14/23 the HVAC on the outside of the house next to the garage caught fire. There were 3 staff members present at that time. Upon realizing the fire had started the staff called 911 and brought all residents outside to the front of the house. The staff then called the Licensee who also arrived. Staff used the facility fire extinguisher to put out the fire. The fire department arrived after the fore was out and determined that there was no additional active threat. The fire department further determined that the cause was the air conditioner condenser unit failure. The facility property was purchased late in the fall of 2022. LPA Jensen reviewed the home inspection report. The report was written inspector badge # 18350 with Home Inspection Services at 2pm on 8/6/22 and states under section 8.3 "the AC condenser was inspected and no adverse conditions were noted." LPA determined that the facility took all necessary actions needed to ensure the safety of the residents therefore no deficiencies are being issued as a result of this case management. An exit interview was conducted and a copy of this report was provided to Cleo Brelin.the state’s words, verbatim · CDSS document, Jul 3, 2023

Type of visit: Post Licensing

On 2/27/23 at approximately 10:15am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a post licensing visit. LPA Jensen met with Cleo Brelin and explained the purpose of today's visit. The grounds were observed to be well maintained and all paths were free of obstruction. The facility was observed to be sanitary and free of odor. There was adequate furniture throughout the home in the backyard for resident use. LPA Jensen observed night lights in the hallway. The carbon monoxide detector and smoke detector was determined to be in good working order. The first aid kit was observed to be complete with scissors, tweezers, thermometer, manual and various wound dressings. The fire extinguisher was purchased within the last 12 months and is in compliance. The facility maintains a generator and food supply for emergency use. There is a 30 day supply of PPE on hand. The facility was observed to maintain a 2 day supply of perishable food and 7 day supply of non-perishable food. The staff was preparing beef enchilada, salad and mango juice, coffee, and Jello filled with fruit. There is an adequate linen supply on hand. All required signs were observed to be posted in prominent areas for easy viewing by residents and visitors. LPA Jensen interacted with 3 of 3 residents who all stated they are happy in the home and well cared for. LPA Jensen reviewed 3 of 3 resident files and found them to be complete. LPA Jensen observed staff to have criminal background clearance and be associated to the facility. LPA Jensen reviewed 1 staff file and found it to be incompliance. The facility was determined to be in substantial compliance. The Post-Licensing Inspection tool was used during the course of this visit. AN exit interview was conducted and a copy of this report was given to Licensee.the state’s words, verbatim · CDSS document, Feb 27, 2023

Type of visit: Prelicensing

On 11/7/22 at 10:10 am Licensing Program Analyst (LPA) Maja Jensen arrived at facility announced to conduct a pre-licensing inspection. LPA Jensen met with Administrator Cleo Brelin and explained the purpose of today's visit. The facility is a single story structure with one designated entrance. The entrance has a sign in table, COVID-19 precautionary signs, PPE, and a thermometer for COVID-19 Screening. The facility was observed to be sanitary and free of odor. There was adequate furniture and lighting observed throughout the facility. Night lights were observed to be installed in the hallways. The facility has clearance for 6 residents of which 5 may be non-ambulatory and 1 may be bedridden. All doorways were of a sufficient width to accommodate a wheel chair. There are recliners available for each resident within the bedrooms. There is seating for 6 available in the living room, at the dining table and in the backyard. The facility was stocked with sufficient linen, a 30 day supply of PPE, emergency food supply and emergency lighting. The fire extinguisher was purchased in August of 2022 and is in compliance. The carbon monoxide and fire alarm were tested and determined to be in good working order. A first aid kit was observed to be complete with manual, tweezers, scissors and various wound dressings. The emergency disaster plan was reviewed and found to be incompliance. All trash cans were observed to have tight fitting lids. There are two bathrooms in the facility. One bathroom is located in the main hall and the other is an ensuite off of the master bedroom. The bathrooms are both equipped with grab bars at the toilet and in the shower. The shower/bath has non-slip mats available when needed. The water temperature was measured at 115 degrees and is within the required regulatory range of 105 degrees to 120 degrees Fahrenheit. Continued... Continued from LIC 9099... The kitchen has a locked storage area for knives and other sharp objects making these items inaccessible to residents in care. There is a locked cabinet for medication and files available making these items inaccessible to residents in care as well. There was a 7 day supply of non-perishable food available in the pantry. A random sample of food items was checked and no expired food items were found. All appliances were observed to be in good working order. The thermostat in the facility was set for a range of between 72 and 75 degrees Fahrenheit for the comfort of residents and staff. Activities were observed to be available for clients and included, exercise videos, reading materials, bingo and other games. There is a laundry room that is kept locked and is used for storage of all cleaning supplies. Signs were posted throughout the facility to prominently display resident rights, resident council, visiting policies, theft and loss policies and complaint reporting information. The Administrator certificate for Jon Brelin is posted at the facility and is current through 10/8/23. The grounds were observed to be well maintained and all pathways were observed to be clear of obstruction and debris. There is a garden area available for resident use. All screens were observed to be in good repair. Ramps were installed at all exits/entrance ways. A component III presentation was completed Cleo Brelin. The facility was found to be in substantial compliance and has passed the pre-licensing inspection. An exit interview was conducted and a copy of this report was handed to Administrator Cleo Brelin.the state’s words, verbatim · CDSS document, Nov 7, 2022

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Office

Facility Type: RCFE Application Type: INITIAL Capacity: 6 Census (if any clients in care): NO Method: Telephone call with CAB COMP II Participants: BRELIN, CLEO/BRELIN, JON Applicant/administrator Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. 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 8. Discussed the COVID-19 Mitigation Plan & PIN emailedthe state’s words, verbatim · CDSS document, Oct 28, 2022