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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911397
Report Date: 04/21/2022
Date Signed: 04/21/2022 04:05:54 PM

Document Has Been Signed on 04/21/2022 04:05 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: 3DATE:
04/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Gene Carlos, Caregiver
Pamela Lyles, Operations Manager		TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Tricia Danielson and Chinwe Nwogene is conducting a case management visit to address deficiencies observed in conjunction with complaint investigation #18-AS-20220413170732. During this visit LPAs discovered one (1) staff member present without the proper clearances. Staff #1 (S1) reported having had worked for the Licensee for approximately one (1) month and has filled in when needed, but is currently without an assigned work area. S1 reported having had fingerprints done but is waiting for the results. S1 departed the facility without issue. Interview with Operations Manager Pamela Lyles revealed S1 is in the process of getting clearance.

Therefore, based on the observations made during today’s visit, the following deficiency was cited per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted and this reported was provided along with appeal rights and LIC 811- Confidential Names List.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
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 04/21/2022 04:05 PM - It Cannot Be Edited


Created By: Tricia Danielson On 04/21/2022 at 03:34 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: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2022
Section Cited
CCR
80065(i)(1)

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Personnel Requirements- i) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(1) Obtain a California clearance...as required by law or Department regulations. This requirement was not met as evidenced by:
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Lyles states the facility will submit a written statement of understanding of the regulation cited bu POC due date 4/22/2022
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The Licensee did not obtain a criminal record clearance for Staff #1 (S1) prior to S1 beginning employment. This poses an immediate health and safety risk to residents in care.

*Civil penalties were assessed
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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:Deborah Mullen
LICENSING EVALUATOR NAME:Tricia Danielson
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022


LIC809 (FAS) - (06/04)
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