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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201014
Report Date: 04/13/2022
Date Signed: 04/13/2022 12:59:15 PM

Document Has Been Signed on 04/13/2022 12:59 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:BEAUTIFUL MIND HOMEFACILITY NUMBER:
079201014
ADMINISTRATOR:ARENAS, JUAN P.FACILITY TYPE:
735
ADDRESS:4512 BELLE DRTELEPHONE:
(954) 478-0613
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 4DATE:
04/13/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Carol Duenas, LicenseeTIME COMPLETED:
01:10 PM
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On 4/13/20222 at 12:00pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct a health and safety check as a result of the department receiving an incident report. LPA met with Carol Duenas, Licensee and explained the reason for the visit.

Upon arrival, LPA observed total of three (3) staff S1, S2, and S3 and one (1) client in the facility. LPA was informed that the other three (3) clients were at the day program.

During the health and safety check, LPA toured the building with Licensee including but not limited to common areas, bathrooms, bedrooms and outdoor area. Facility is noted to be clean and in good repair and clients in care appear to be safe. There are no imminent health/safety concerns on today's date.

LPA collected documents from C1 and S4 file. (See LIC812).

No deficiencies were cited today.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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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