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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201007
Report Date: 12/09/2022
Date Signed: 12/09/2022 05:53:24 PM

Document Has Been Signed on 12/09/2022 05:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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: 6DATE:
12/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:32 PM
MET WITH:Rene Rodriguez, AdministratorTIME COMPLETED:
06:00 PM
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On 12/09/22 at 5:32PM, while at the facility for another reason, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced case management visit to follow up on client's (C1) status regarding the 30 day eviction issued by the facility due to violation of house rules and using drugs inside her bedroom.

Administrator stated they continue to work with C1, her conservator, counselors from the START program, RCEB behavior specialist and RCEB case manager in addressing her behavioral needs and efforts to safely relocate her to another location.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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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