Cleo's Home 4

Type of visit: Required - 1 Year

Unannounced Annual visit made out to this facility on 11/06/2025 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 3 residents. It was learned that there were (2) 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 (2) 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, # 7026588740, for Jon Brelin was observed to have an expiration date of 10/08/2027 and in compliance at this time. Forms and documents have been completed in order to renew this Administrator certificate at this time. Medication cabinet, located in the facility kitchen cabinet , was observed to be locked and made inaccessible to the residents at this time. First aid kit, located in the medication 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 annually inspected by the local fire extinguisher company, Butch Young Fire, with the inspection date of 01/02/2025 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 (3) facility personnel records was conducted on the LIC 859. A review of (3) 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 annual visit. Exit Interviewthe state’s words, verbatim · CDSS document, Nov 6, 2025

Type of visit: Required - 1 Year

Unannounced Annual visit made out to this facility on 11/04/2024 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 3 residents. It was learned that there were (2) 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, # 6061026740, for Jon Brelin was observed to have an expiration date of 10/08/2023 and in compliance at this time. Forms and documents have been completed in order to renew this Administrator certificate at this time. Medication cabinet, located in the facility kitchen cabinet , was observed to be locked and made inaccessible to the residents at this time. First aid kit, located in the medication 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 annually inspected by the local fire extinguisher company, Butch Young Fire, with the inspection date of 01/08/2024 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 (3) facility personnel records was conducted on the LIC 859. A review of (3) 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 annual visit. Exit Interviewthe state’s words, verbatim · CDSS document, Nov 4, 2024

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