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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200949
Report Date: 04/23/2024
Date Signed: 04/23/2024 01:03:47 PM

Document Has Been Signed on 04/23/2024 01:03 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MINNESOTA HOMES RESIDENTIAL FACILITYFACILITY NUMBER:
079200949
ADMINISTRATOR/
DIRECTOR:		ABEL, CHRISTOPHERFACILITY TYPE:
735
ADDRESS:1003 CHAMOMILE LANETELEPHONE:
(763) 350-0360
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 3DATE:
04/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Caregiver, Kelsey EscuetaTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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On 4/23/2024 at 10:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Kelsey Escueta and explained the purpose of the visit. Administrator Christopher Abel arrived at 11:25AM. The facility’s fire clearance was approved for 6 Ambulatory.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms. All outdoor and indoor passageways are kept free of obstruction. Pool area is locked and secured. A comfortable temperature for clients is maintained at 69 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 113.1 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygienes were available for clients. There is a minimum of one week supply of non-perishables and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 7/12/2023. Emergency Disaster Drill was last posted on 4/02/2024. First aid kit was observed to be complete. Fire drill was last conducted on 4/01/2024.

At 11:00am, 3 of 3 clients records were reviewed. At 11:30am, 5 staff records were reviewed and 5 of 5 have current first aid training and associated to the facility.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2024
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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