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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911397
Report Date: 08/04/2023
Date Signed: 08/04/2023 09:45:03 AM

Document Has Been Signed on 08/04/2023 09:45 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
RIVERSIDE ASC, 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:
08/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Gene Carlos, CaregiverTIME COMPLETED:
09:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to the facility to initiate an investigation. Refer to 18-AS-20230731084049. LPA met with Caregiver Gene Carlos and explained the purpose of today's visit.

LPA toured the facility, and found that the washer is inoperable for client use. The washer has been reported to Community Valley Homes by staff; however, the washer remains to not be fixed after approximately a month of the issue being known by staff. In-house staff stated that they have been utilizing their own home to wash the client's clothes. Thus, the facility was issued a citation per Title 22.

An exit interview was conducted where a copy of this report was discussed with and provided to Carlos along with the LIC809-D, and Appeal Rights.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
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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Document Has Been Signed on 08/04/2023 09:45 AM - It Cannot Be Edited


Created By: Jesse Gardner On 08/04/2023 at 09:01 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
, 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: 08/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2023
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not being met as evidenced by:
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Licensee agrees to fix or replace the washer and show proof of such to LPA by POC date.
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Based on staff interview, the washer has been inoperable for approximately a month, and staff has been utilizing their own home to clean client's clothes. This presents a potential personal rights risk to residents 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:Joel Esquivel
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023


LIC809 (FAS) - (06/04)
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