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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201014
Report Date: 09/15/2022
Date Signed: 09/15/2022 10:49:13 AM

Document Has Been Signed on 09/15/2022 10:49 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: DATE:
09/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Daniela Mesa, CaregiverTIME COMPLETED:
10:55 AM
NARRATIVE
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On 9/15/2022 at 9:55AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Daniela Mes, Caregiver and explained the purpose of the visit. LPA spoke with Administrator, Juan Arenas, via telephone. Administrator gave approval for Caregiver to sign documents.

This visit is based on an incident report received on 4/9/2022 and a case management visit conducted on 4/13/2022. During the visit on 4/13/2022 LPA reviewed S3’s file and observed that S3 did not have a complete personnel file and had not been fingerprinted. S1 stated that finding staff had not been easy and that the facility had S3 on trial work training before completing all necessary documents.

The following deficiencies were observed:

· LPA observed during record review and interview that S1 did not have a criminal record clearance.

· LPA observed Administrator did not perform the duties of employment and training of qualified staff.

· LPA observed that S3 did not have a complete personnel file.

Continued on LIC809C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BEAUTIFUL MIND HOME
FACILITY NUMBER: 079201014
VISIT DATE: 09/15/2022
NARRATIVE
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Continued from LIC809.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies 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: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/15/2022 10:49 AM - It Cannot Be Edited


Created By: Laura Hall On 09/15/2022 at 10:14 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BEAUTIFUL MIND HOME
FACILITY NUMBER: 079201014

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2022
Section Cited
CCR
85064(j)(3)

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85064 Administrator Qualifications and Duties
(j) The administrator shall perform the following duties:
(3) Recruitment, employment and training of qualified staff, and termination of staff.
This requirement was not met as evidence by:

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Administrator agreed to submit a written plan of correction stating what plan has been implemented to train Administrators to perform duties and submit the plan to CCLD by POC date.
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Based on LPA's observation and record review the Licensee did not comply with the section cited above in applying the duties and qualifications as an Administrator, which posed an immediate health and safety risk to person in care.
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Type A
09/16/2022
Section Cited
CCR80019(d)(2)(A)

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80019 (d) All individuals... shall be fingerprinted and sign a Criminal Record Statement ....
(2) The licensee shall submit these fingerprints...(A) Fingerprints shall be submitted to... by the licensee.., or sent by electronic transmission to...by a fingerprinting entity...This requirement was not met as evidence by:
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 Licensee agreed to submit a written plan on what steps Administrator will take to not let this occur in the future and submit plan to CCLD by POC date.
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Based on LPA's record review the licensee did not comply with the section cited above in having S3 fingerprinted before working at the facility, which posed an immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2022 10:49 AM - It Cannot Be Edited


Created By: Laura Hall On 09/15/2022 at 10:31 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BEAUTIFUL MIND HOME
FACILITY NUMBER: 079201014

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2022
Section Cited
CCR
80066(a)

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80066 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on... each employee. Each personnel record shall contain the following information: This requirement was not met as evidence by:
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Based on LPA's record review the licensee did not comply with the section cited above in having the personnel record completed, which posed an immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022


LIC809 (FAS) - (06/04)
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