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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911397
Report Date: 06/22/2023
Date Signed: 06/22/2023 03:59:24 PM

Document Has Been Signed on 06/22/2023 03:59 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 AC/SC, 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:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Caregiver Bonifacio CarlosTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Janette Romero conducted an unannounced annual required visit to the facility at 2:15 p.m. LPA was greeted and granted entry by Caregiver Bonifacio Carlos who was informed of the purpose of the visit; Operations Manager Pamela Lyles later arrived. During the visit, there was two (2) clients, and one (1) staff present.

The facility is made up of a one-story home with three (3) bedrooms, two (2) bathrooms, family room, dining area, kitchen, and an attached garage. LPA conducted a tour of the interior and exterior, and reviewed facility documents. LPA observed the following:

Bedrooms: Client bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Both bathrooms have a working toilet, wash basin, and were equipped with a grab bar in the shower. The facility has clean towels, blankets, and linen, available in different colors for each client.

Kitchen: LPA observed a sufficient supply of dishes, glasses, utensils, pots, and pans. Sample menu is posted on refrigerator wall. The stove is operational. Refrigerator and freezer were in working condition. LPA observed sufficient perishable and non-perishable food available for the clients in care. A fire extinguisher was placed on kitchen counter-top, which expired in April of 2023. Sharps and knives are secured in a locked cabinet in the kitchen. Cleaning solutions are secured in a locked cabinet under the sink.

Continued on LIC809-C..
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BETA RESIDENTIAL HOME
FACILITY NUMBER: 330911397
VISIT DATE: 06/22/2023
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Laundry: Laundry area had a washer and dryer.

Centrally Stored Medications: LPA observed a first aid kit with medical shears missing. Client medications are secured in a locked kitchen cabinet.

Living/Family room: The family room had a working television. Personal rights posters, emergency phone numbers, and facility sketch were posted in living room area and entrance hallway.



Yard/Outside Area: A gate secured the entire backyard. LPA observed a pool and spa in the backyard with a secured gate, making it inaccessible for clients in care. All outdoor pathways were free of obstructions. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

Technical Advisories: Recharge fire extinguisher, put up Let-Us-No poster, conduct staff training regarding Mandated Reporter Requirements, and add medical shears to first-aid kit.

There were no deficiencies noted at the time of the visit. An exit interview was conducted, and a copy of this report was reviewed and provided to facility Operations Manager Lyles.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
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