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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911397
Report Date: 06/18/2024
Date Signed: 06/18/2024 11:48:02 AM

Document Has Been Signed on 06/18/2024 11:48 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
CCLD Regional Office, 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: 1DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Bonifacio "Gene" Carlos, Facility ManagerTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that one (1) client reside at this facility and there are currently two (2) caregivers present. There is no Infection Control Plan on file.

Client Records-Incident Reports/Clients Rights-Information/Dental- LPA began review of client records. One (1) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

Personnel Records/Training/and Staffing- LPA began review of employee records- Two (2) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening-one missing and TB test results-one missing, employee rights-two missing, training verification-one missing, and LPA is unable to verify administrator certification; 12/22/2022 expiration date.



Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen.

(Continued on LIC809C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 330911397
VISIT DATE: 06/18/2024
NARRATIVE
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(Continuation from LIC809)

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPA observed the facility to be clean and not in good repair. The home is maintained at a comfortable temperature for the clients. Lighting is not sufficient for safety and comfort. Water temperature measured 118.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor passageways are not free from obstruction and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this home. This home does have a pool and is locked at all times with fencing that is more than 5 ft. high around the perimeter of the pool; green water observed.

Medications- are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.

P&I- was reviewed. LPA observed that the facility maintains a separate log for each individuals’ monies. LPA was unable to verify monies.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguisher is current, 06/18/2024. The facility is conducting emergency disaster/fire drills monthly; last done on 06/1/2024.

Based on the information received during this visit today in the areas reviewed, eight (8) deficiencies, one Technical violation are being cited per Title 22, Division 6 of The California Code of Regulations.

This LIC 809, 809D and Appeal rights reports was reviewed with the facility representative and copies was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/18/2024 11:48 AM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/18/2024 at 10:59 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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 met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in broken floor tile in the kitchen, broken kitchen drawers, light covers for kitchen missing, missing lights in kitchen, broken light covers in Master bedroom, pool water is green, south gate door latch is loose, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2024
Plan of Correction
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2
3
4
Licensee will repair items and email pictures to LPA by POC due date.
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in outdoor passageway has overgrown grass which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2024
Plan of Correction
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4
Licensee will have overgrown grass cut and email pictures to LPA by POC due date.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/18/2024 11:48 AM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/18/2024 at 10:59 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in Master bedroom is missing a night stand which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2024
Plan of Correction
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Licensee will obtain a night stand and email picture to LPA by POC due date.
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in no night light observed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2024
Plan of Correction
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Licensee will obtain night lights for hallways and email photographs to LPA by POC due date.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/18/2024 11:48 AM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/18/2024 at 10:59 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in no outdoor furniture observed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2024
Plan of Correction
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Licensee will obtain outdoor furniture with shade and email photograph to LPA by POC due date.
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in S1 did not have a health screening in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2024
Plan of Correction
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Licensee will ensure S1 has a health screening and email a copy to LPA by POC due date.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 06/18/2024 11:48 AM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/18/2024 at 10:59 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in S1 TB test document was not in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2024
Plan of Correction
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2
3
4
Licensee will ensure S1 obtain a TB test and email document to LPA by POC due date.
Type B
Section Cited
CCR
80092.1(l)
General Requirements for Restricted Health Conditions
(l) All training shall be documented in the facility personnel files.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in S1 had no training documents in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2024
Plan of Correction
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2
3
4
Licensee will provide copies of S1 trainings by email to LPA by POC due date.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
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