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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200949
Report Date: 09/12/2024
Date Signed: 09/12/2024 10:29:11 AM

Document Has Been Signed on 09/12/2024 10:29 AM - 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: 4DATE:
09/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Kelsey Escuerta, CaregiverTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 09/12/2024 at 9:20AM, Licensing Program Analyst (LPA) T.Syess-Gibson conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 09/09/2024. LPA met with Kelsey Escuerta, Caregiver and explained the purpose of the visit. Kelsey contacted Logan Blair, House Manager and explained the purpose of my visit. House Manager, Logan arrived at approximately 9:56AM. LPA explained purpose of visit.

Incident reported occurred on 09/09/2024 that involved client 1 (C1) AWOL'g while staff was picking up dinner in Concord CA. The facility contacted Concord Police Department 9-1-1 and was transferred to Plesant Hill Police Department , The Pleasant Hill Police looked for C1 and was unsuccessful in locating him. C1 admission agreement is dated 09/03/2024, AWOL'd on 09/09/2024, and returned to the facility on 09/10/2024 at 1:30AM. LPA reviewed C1 IPP (RCEB) which indicates C1 is independent.


No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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