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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200949
Report Date: 03/23/2023
Date Signed: 03/23/2023 03:36:04 PM

Document Has Been Signed on 03/23/2023 03:36 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Christopher Abel, Administrator TIME COMPLETED:
03:45 PM
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On this day 03/23/2023 at around 10:15AM, Licensing Program Analyst (LPA) L. Ibo arrived at the facility to conduct annual required inspection. LPA was met by caregiver S2. Administrator Christopher Abel arrived at around 10:30AM.

LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, garage dining and living areas. The facility has 4 bedrooms and 3 bathrooms. One bedroom is designated as staff room. There are 3 clients observed. Facility has an approved fire clearance for 6 ambulatory clients. Two fire extinguishers that was bought on June 22, 2022.

Facility has sufficient supply of perishable and non-perishable foods. There are 2 staff working during the visit and both are fingerprint cleared. Bathrooms were observed with grab bars and nonskid mats.

LPA reviewed 3 clients and 3 staff files and interviewed 3 clients and 3 staff. Facility has wired carbon monoxide and smoke detector that were observed functional. Facility has a current liability insurance.

At approximately 10:23AM, LPA observed disinfectants unlocked under the sink.

Deficiencies are being cited today in violation of California Code of Regulations and follows on 809D. Failure to submit proof of corrections (POC's) along with LIC9098 by plan of correction due dates may result in civil penalty.

Exit interview was conducted with Administrator and Appeal Rights was 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
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 03/23/2023 03:36 PM - It Cannot Be Edited


Created By: Leslie Ibo On 03/23/2023 at 03:08 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MINNESOTA HOMES RESIDENTIAL FACILITY
FACILITY NUMBER: 079200949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 staff failed to lock kitchen sink where the disinfectant were located which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2023
Plan of Correction
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Cleared and corrected during the visit.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
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