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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201007
Report Date: 04/17/2025
Date Signed: 04/17/2025 03:56:03 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
04/14/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250414104550
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:
04/17/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:TIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not providing adquate food service to residents
Staff do not have adequate toiletries for residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 04/17/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM.

During investigation, the department conducted interviews and obtained the following documents from administrator – Clients’ roster, Personnel Record (LIC500) / Work Schedules, Admission agreements, medical records, activities schedules, incident reports, meal schedules, Needs & Services plans, physicians’ reports.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
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 5
Control Number 15-AS-20250414104550
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: 04/17/2025
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
Allegation: Staff are not providing adequate food service to residents
Investigation Finding: Substantiated
During investigation, LPA observed that the facility does not have an adequate supply of food at the facility. The facility has a total of 5 clients with 2 clients diagnosed with diabetes. On 04/17/25 at 1PM, LPA toured the facility with staff (ADM, S1) including but not limited to the kitchen, common areas and garage. LPA observed half a tray of fresh eggs, some vegetables, milk, juice, condiments, frozen ground meat, hot pockets, pizzas, cheese in the refrigerator / freezer as well as a limited supply fresh fruit on the kitchen counter top (2 apples, a bag of clementines and one banana). Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that are not providing adequate food service to residents was found to be substantiated.
Civil penalty of $250 assessed during visit for repeat violation of Section 85076 (d)(1).

Allegation: Staff do not have adequate toiletries for residents
Investigation Finding: Substantiated
On 04/17/25 at 1PM, LPA toured the facility and observed a limited supply of paper products (paper towels and toilet paper) in the clients’ bathrooms, kitchen and garage storage cabinets. LPA observed the facility did not have a minimum 30 days supply of paper towels and toilet paper. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff do not have adequate toiletries for residents was found to be subtantiated.

Deficiency is 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, appeal rights and copy of report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20250414104550
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: 04/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2025
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
Civil penalty of $250 assessed during visit for repeat violation of Section 85076(d)(1).
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
Administrator agreed to purchase food and submit photos of food to CCLD by POC date.
Type B
05/12/2025
Section Cited
CCR
80088(e)(3)
1
2
3
4
5
6
7
All toilets, hand washing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.
1
2
3
4
5
6
7
Administrator agreed to purchase additional paper supplies and submit photos of paper supplies 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 adequate supply of toiletries (minimum 30 days) which posed a potential health & safety risk to residents 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: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
04/14/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250414104550

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:
04/17/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:TIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not meeting resident's dietary needs
Staff are not providing adequate outings for residents
Staff are not providing adequate transportation for residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 04/17/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM.

During investigation, the department conducted interviews and obtained the following documents from administrator – Clients’ roster, Personnel Record (LIC500) / Work Schedules, Admission agreements, medical records, activities schedules, incident reports, meal schedules, Needs & Services plans, physicians’ reports.

Continued on next page, LIC 9099-C pg2
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20250414104550
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: 04/17/2025
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
Allegation: Staff are not meeting resident’s dietary needs
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed clients (C1, C2, C3,C4) and staff (ADM, S1). Review of clients (C1, C2) medication administration records showed that they are prescribed diabetic medication (Metformin). LPA observed C1 eating a salad for lunch during visit. C1 confirmed with LPA that staff provide him with healthy meals (breakfast, lunch and dinner) daily with diet drinks. Other clients (C2, C3, C4) confirmed with LPA that staff provide them with adequate meals and that they are satisfied with the food service. Although the allegation that staff are not meeting resident’s dietary needs may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, this allegation is unsubstantiated.

Allegation: Staff are not providing adequate outings for residents
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed clients (C1, C2, C3,C4) and staff (ADM, S1). Clients (C1, C2) confirmed with LPA that they prefer to go out with friends and family to eat out while clients (C3, C4) like going to restaurants (Popeyes, MacDonalds) and the Dollar Tree store. Clients C3, C4 attend their day program weekly where they participate in community based activities. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff are not providing adequate outings for residents is unsubstantiated.

Allegation: Staff are not providing adequate transportation for residents
Investigation Finding: Unsubstantiated
During investigation, clients (C1, C2, C3, C4) confirmed with LPA that staff (ADM, S1) assist them in scheduling their primary care physician’s appointments and drive them to their scheduled check-ups and follow-up visits. Review of clients (C1, C2, C3, C4) after visit summary reports showed that each client completed their doctors’ appointments as scheduled. On 12/05/24, LPA observed client (C3) coming back from a doctors’ appointment accompanied by staff who drove her to the scheduled doctor’s visit. Clients also confirmed with LPA that staff assist them in purchasing personal items and favorite food when requested. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff are not providing adequate transportation for residents is unsubstantiated. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5