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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200949
Report Date: 03/23/2023
Date Signed: 03/23/2023 04:40:38 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/18/2022 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20220918085051
FACILITY NAME:MINNESOTA HOMES RESIDENTIAL FACILITYFACILITY NUMBER:
079200949
ADMINISTRATOR:ABEL, CHRISTOPHERFACILITY TYPE:
735
ADDRESS:1003 CHAMOMILE LANETELEPHONE:
(763) 350-0360
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 3DATE:
03/23/2023
UNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Christopher Abel, Administrator TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility staff restrained resident in an abusive manner
INVESTIGATION FINDINGS:
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On 03/23/2023 at 3:55PM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver findings in regard to the allegation above. LPA met with Administrator, Christopher Abel and explained the purpose of the visit.
During the course of investigation, LPA interviewed 3 clients and 3 staff. LPA obtained and reviewed physician's report, staff training records, medication records, clients personal care chart, clients individual service plans, hospital records and other documents pertaining to the allegation above.

Based on the course of investigation, records review revealed that C1 had history of aggressive behaviors with history of 5150’s. C1 was going through medication changes during the period of first week of August 2022 and the second week of August 2022. Based on interview with staff, one of the staff (S3) was punched by C1. Staff had to restrained C1 that lasted for 10-15 seconds while calling the police. Police arrived and C1 was taken to the hospital and came back at the facility after few days. During the interview C1 denied being hurt during the restrained process. ....Continues to LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20220918085051
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MINNESOTA HOMES RESIDENTIAL FACILITY
FACILITY NUMBER: 079200949
VISIT DATE: 03/23/2023
NARRATIVE
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 Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2