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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911397
Report Date: 02/11/2025
Date Signed: 02/11/2025 05:32:44 PM

Document Has Been Signed on 02/11/2025 05:32 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
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:
(951) 243-1911
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 4CENSUS: 2DATE:
02/11/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:15 PM
MET WITH:Staff, Bonifacio CarlosTIME VISIT/
INSPECTION COMPLETED:
05:35 PM
NARRATIVE
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Licensing Program Analysts (LPA)’s Janira Arreola and Abdoulaye Zerbo, conducted an unannounced visit to the facility to conduct a Case Management Visit. The purpose of this report is to document the deficiencies observed during the visit. LPAs met with Staff, Bonifacio Carlos who was informed of the purpose of the visit. The Licensee was not available over phone at the time of the visit. LPAs conducted a walk through, conducted interviews and records review.

During today's visit LPAs toured the home and conducted a health and saftey check on the facility and clients. No immediate issues were observed.

LPAs observed the facility yard has a gated and locked pool with green opaque water half way full. This was cited and a plan of correction was created.

An deficiency was discovered during file review of the facility. The facility has an outstanding fee balance for $681.00 that was due 06/14/2024.The licensee stated they would pay the outstanding the balance. Therefore the facility is being cited for not paying their annual licensing fees.

An exit interview was conducted where this report along with the LIC809D page, and appeal rights were reviewed and provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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 02/11/2025 05:32 PM - It Cannot Be Edited


Created By: Janira Arreola On 02/11/2025 at 05:02 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: 02/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2025
Section Cited
CCR
87303(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision…for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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POC is to ensure the pool is clean and provide proof by the POC due date.
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Based on observation and interview, the facility pool is in unsanitary conditions. This posed a potential health, safety, or personal rights risk to clients in care.
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Type B
02/14/2025
Section Cited
CCR80036(a)

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(a) An applicant or a licensee shall be charged fees as specified in Health and safety Code Section 1523.1. This requirement was not met as evidenced by:
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The POC is to pay the annual fees and show proof of this by the POC due date.
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Based on file review the licensee did not pay their annual fees and accrued a late fee. This poses a potential health, safety, or personal rights risk to clients 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:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
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