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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201014
Report Date: 08/17/2022
Date Signed: 08/17/2022 11:40:48 AM

Document Has Been Signed on 08/17/2022 11:40 AM - 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:
(925) 978-9486
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 4DATE:
08/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Carol Duenas, LicenseeTIME COMPLETED:
11:50 AM
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On 8/17/2022 at 11:20AM Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Carol Duenas, Licensee.

LPA went to the facility to deliver an Immediate Exclusion letter. LPA verified that S1 was no longer present or working at the facility.

No deficiencies cited during visit.

Exit interview conducted. A copy of exclusion letter and report provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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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