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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201007
Report Date: 12/17/2021
Date Signed: 12/17/2021 01:04:58 PM

Substantiated


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
12/14/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20211214114129
FACILITY NAME:BELTRAN'S PLACEFACILITY NUMBER:
079201007
ADMINISTRATOR:RODRIGUEZ, RENE ELIASFACILITY TYPE:
735
ADDRESS:4645 APPLEGLEN STTELEPHONE:
(904) 859-1773
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 5DATE:
12/17/2021
UNANNOUNCEDTIME BEGAN:
11:53 AM
MET WITH:Rene Rodriguez, AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility did not have required staffing
INVESTIGATION FINDINGS:
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On 12/17/21 at 11:53AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, met with administrator and explained the purpose of the visit.
LPA observed 3 masked staff assisting 2 clients with snacks in the kitchen while the other clients were resting inside their bedrooms.

During investigation, LPA interviewed administrator, S1 and S2. Based on LPA’s observations and interviews which were conducted and record review(s), facility did not have the required staff to provide 1:1 care and supervision for a respite client on the night shift (NOC). The preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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-20211214114129
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: BELTRAN'S PLACE
FACILITY NUMBER: 079201007
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2021
Section Cited
CCR
85065.6
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NIght Supervision
(g) In facilities providing care to Regional Center clients who rely upon others to perform all activities of daily living, night supervision shall be maintained as required by the Regional Center,
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Administrator agreed to submit to CCLD on or before POC due date a self certification that staff has read and will comply with Section 85065.6
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This requirement was not met as evidenced by facility not having required staffing for 1:1 client care which posed a potential health & safety risk to clients in care
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2