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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911397
Report Date: 07/11/2022
Date Signed: 07/11/2022 05:13:00 PM

Document Has Been Signed on 07/11/2022 05:13 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BETA RESIDENTIAL HOMEFACILITY NUMBER:
330911397
ADMINISTRATOR:MARTIN, MARYFACILITY TYPE:
735
ADDRESS:12035 HINSON STREETTELEPHONE:
(951) 243-1911
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 4CENSUS: 2DATE:
07/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Staff- Pamela Lyles TIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit to the facility for the purpose of conducting an annual focused on infection control. LPA was greeted by facility Administrator Pamela Lyles, who was informed of the purpose of the visit.

LPA toured the interior and exterior of the facility. At the time of the visit there were 2 clients and 4 staff present. LPA observed COVID-19 postings at the facility, as well as a central entry point and sign in and screening process. LPA will issue technical advisory note for the facility to start documenting client and staff temperatures daily. LPA toured resident rooms which will be used as isolation rooms. LPA observed C1 had oxygen in his room, LPA will document Technical advisory note for oxygen no smoking sign, and fire department notification to be made. LPA observed a sufficient amount of paper towels, toilet paper, hand soap, and hand sanitizer in facility restrooms. LPA observed a sufficient supply of PPE equipment at the facility. LPA will document technical advisory note for staff to be trained in PPE usage and to be N95 FIT tested. There is a cleaning plan in place to disinfect the highly touched surfaces, and a plan in place to monitor the clients regularly for any changes in condition.

LPA was informed of the fact that C1 was admitted to hospice recently and observed client to have hospice bed and oxygen in their room. The facility currently does not have an approved hospice waiver issued by the department. LIC809-D will be document with Type B citation for this.

An exit interview was conducted where this report along with LIC9102TA and LIC 809-D forms were reviewed and provided to Administrator, Pamela Lyles.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2022
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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Document Has Been Signed on 07/11/2022 05:13 PM - It Cannot Be Edited


Created By: Janira Arreola On 07/11/2022 at 04:44 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BETA RESIDENTIAL HOME
FACILITY NUMBER: 330911397

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85075.1(a)(1)

85075.1 HOSPICE CARE

(a) A licensee shall be permitted to retain terminally ill clients who receive hospice services from a hospice agency or to accept terminally ill persons as clients if they are already receiving hospice services from a hospice agency and would continue to receive those services without disruption after becoming a client, when all of the following conditions (1) through (7) are met:

(1) The licensee has received a facility hospice care waiver from the Department

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above with C1 that have been admitted to hospice, while the facility does not have an approve hospice waiver. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2022
Plan of Correction
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Licensee is to submit a hospice waiver to the department in order to retain the hospice client. This will submitted to the LPA by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022


LIC809 (FAS) - (06/04)
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