<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201007
Report Date: 06/13/2024
Date Signed: 06/13/2024 05:08:01 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
06/03/2024 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240603125124
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:
06/13/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Fabiola Fernandez Ramos, Direct Support ProfessionalTIME COMPLETED:
05:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff not following residents dietary needs.

Staff not providing residents nutritious meals.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6/13/2024 at 3:00pm, Licensing Program Analyst (LPAs) L. Hall arrived to conduct an initial 10-day complaint investigation. LPA met with Fabiola Fernandez Ramos, Direct Care Staff (DSP). Administrator, Jose Rodriguez arrived at 3:30pm and LPA explained the reason for the visit.

Based on observation facility did not have a 7-day supply of non-perishables and 2-day perishable foods. LPA observed 1 apple and 2 bananas and no snacks. LPA did observe some can goods and frozen foods (waffles, fish filets, hot pockets, etc). LPA did not observe an additional refrigerator or freezer LPA obtained and reviewed the food menus for 4/1 to 4/7; 5/6 to 5/12; and 5/27 to 6/2, which was exactly the same. The menu did not have any nutritious meals planned.

Continued on LIC9099C.



Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
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 3
Control Number 15-AS-20240603125124
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: 06/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2024
Section Cited
CCR
85076(d)(1)
1
2
3
4
5
6
7
(d) The licensee shall meet the following food supply and storage requirements: (1) ...nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to purchase food and submit photos of food to CCLD by POC date.
8
9
10
11
12
13
14
Based on observation the Licensee did not comply with the section cited above in having a 7-day non-perishable and 2-day perishable, which poses a potential health and safety risk for persons in care.
8
9
10
11
12
13
14
Type B
06/17/2024
Section Cited
CCR
80076(6)
1
2
3
4
5
6
7
80076 Food Services ( 6) Modified diets prescribed by a client's physician as a medical necessity shall be provided.
This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to purchase healthy food and submit photos of food to CCLD by POC date.
8
9
10
11
12
13
14
Based on observation the Licensee did not comply with the section cited above in having health foods for clients, which poses a potential health and safety risk for persons in care.
8
9
10
11
12
13
14
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: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240603125124
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
VISIT DATE: 06/13/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099.

Based on review of client records there is one (1) client that requires a modified diet. LPA did not observe healthy foods for clients.

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

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3