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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201014
Report Date: 12/14/2023
Date Signed: 12/14/2023 11:14:21 AM

Document Has Been Signed on 12/14/2023 11:14 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:
12/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Carol Duenas, LicenseeTIME COMPLETED:
11:15 AM
NARRATIVE
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On 12/14/2023 at 10:45am, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a case management visit. This is a follow-up visit pertaining to a self reported incident regarding a client being injured by a staff person on April 9,2022.

On April 9, 2022, Client 1 (C1) was stabbed in the head, back and arm by Staff 3 (S3). LPA met with Carol Duenas, Licensee, and explained the reason for the visit.

The Department obtained and reviewed records from the facility, Antioch Police Department (APD), John Muir Medical Center, but was not limited to interviews with current staff and witnesses.

Client 1 (C1) was taken to John Muir Medical Center and treated with 33 stitches to close four (4) stab wounds. C1 was released and returned to the facility the same day of the incident.

Based on the investigation, including self reported incident report, C1 sustained injuries from S3. S3 was a new employee and was not properly trained to redirect clients with aggressive and /or violent behaviors. Based on staff interviews, S3 was being shadowed by another employee when the incident occurred. C1 has a history of violent behavior towards staff. The licensee did not have a personnel record for S3 and S3 was not fingerprint cleared. During the case management visit on September 15, 2022, licensee was cited for these 2 violations. The Department issued an immediate exclusion notice to S3 and delivered it to the facility on August 17,2022.

Continued on LIC809C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023
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: 12/14/2023
NARRATIVE
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Continued from LIC809.

Deficiency is cited under the California Code of Regulations, Title 22, Division 6, follows on LIC809D.

A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to injury of client is pending.

Exit interview conducted. A copy of the appeal rights, LIC421IM, and this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/14/2023 11:14 AM - It Cannot Be Edited


Created By: Laura Hall On 12/14/2023 at 10:54 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: 12/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/09/2024
Section Cited
CCR
80072(a)(3)

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80072 Personal Rights (a)... each client shall have personal rights which include... the following: (3) To be free from corporal or unusual punishment, infliction of pain... threat, mental abuse... This requirement was not met as evidence by:
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Licensee agrees to attend the non compliance meet (NCC) on POC due date at 10:30am.
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Based on record review and observation the Licensee did not comply with the section cited above in keeping client safe which poses an immediated 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: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023


LIC809 (FAS) - (06/04)
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