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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200949
Report Date: 03/05/2025
Date Signed: 03/05/2025 11:49:15 AM

Document Has Been Signed on 03/05/2025 11:49 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: 3DATE:
03/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Galvin Escueta, Direct Care StaffTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 03/05/2025 at 9:30AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year required inspection. LPA met with Gelvin Escueta, Staff, and explained the purpose of the visit. Gelvin Escueta contacted Administrator via telephone. Logan Blair, House Manager arrived at 10:20AM. LPA toured the facility with, Logan Blair, House Manager. The facility’s fire clearance was approved for six (6) ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) total bedrooms and three (3) bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 68 degrees 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 108.5 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for clients. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 07/29/2024. Emergency Disaster Plan was last posted on 07/01/2024. First aid kit was observed to be complete. Fire drill was last conducted on 02/01/2025.

Continued on LIC9099C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MINNESOTA HOMES RESIDENTIAL FACILITY
FACILITY NUMBER: 079200949
VISIT DATE: 03/05/2025
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Continued from LIC9099

Four (4) staff records reviewed and complete. All three (3) clients records reviewed and complete. LPAs also reviewed P & I during visit.

The following forms to be updated and submitted to CCLD by 03/12/2025:

· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond
· LIC610D emergency disaster plan
· Client roster
· LIC308 Designation of facility responsibility



No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC809 (FAS) - (06/04)
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