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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911397
Report Date: 11/14/2024
Date Signed: 11/15/2024 07:55:52 AM

Document Has Been Signed on 11/15/2024 07:55 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/
DIRECTOR:		MARTIN, MARYFACILITY TYPE:
735
ADDRESS:12035 HINSON STREETTELEPHONE:
9512431911
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 4CENSUS: 2DATE:
11/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:05 PM
MET WITH:Bonifacio CarlosTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs),Abdoulaye Zerbo and Armando Perez conducted an unannounced visit to the facility for a health an safety check. The LPAs met with manager Bonifacio Carlos, and informed him of the purpose for the visit and were granted access.

The facility is a single story building and consists of three (3) resident bedrooms, two (2) bathrooms and a gated pool meeting the department's requirements. There are currently two (2) residents in care. LPAs toured the facility for the purpose of a health and safety check. LPAs observed five (5) broken tiles in the kitchen next to the sink. A citation will be given. LPAs did not observe sufficient lighting in both living rooms areas and in the kitchen area. A citation will be given.

LPAs were not able to obtain the LIC 500 as the facility did not have it on site. A citation will be issued. LPAs observed current personnel to be fingerprint cleared.

An exit interview was conducted, and a copy of this report along with the appeal rights was provided to facility manager Bonifacio Carlos.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 11/15/2024 07:55 AM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 11/14/2024 at 04:15 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: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2024
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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The administrator will repair or replace broken tiles through out the facility and send picture of completion by the POC due date
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Based on observation and interview, the licensee did not comply with the section cited above in 5 of 5 tiles in the kitchen, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
11/28/2024
Section Cited
CCR85066(b)(1)(2)(3)(4)

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85066 Personnel Records

(b) A dated employee time schedule shall be developed at least monthly, shall be displayed conveniently for employee reference and shall contain the following information for each employee:

(1) Name.

(2) Job title.

(3) Hours of work.

(4)Days off.
This requirement is not met as evidenced by:
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Licensee agreed to send proof of personel roster by POC due date.
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Based on observation and interview, the licensee did not comply with the section cited above in one of one file, which poses/posed a potential health, safety or personal rights 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:Rikesha Stamps
LICENSING EVALUATOR NAME:Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/15/2024 07:55 AM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 11/14/2024 at 04:43 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: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2024
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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The administrator will repair or replace the missing or defective light bulbs through out the facility and send picture of completion by the POC due date
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Based on observation and interview, the licensee did not comply with the section cited above in 3 of 3 light bulbs not working in the kitchen, the living room by the front door and the living room by the kitchen which poses/posed a potential health, safety or personal rights 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:Rikesha Stamps
LICENSING EVALUATOR NAME:Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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