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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911397
Report Date: 05/29/2025
Date Signed: 05/29/2025 05:29:48 PM

Document Has Been Signed on 05/29/2025 05:29 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:
05/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Staff, "Gene" Bonifacio CarlosTIME VISIT/
INSPECTION COMPLETED:
05:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA met with Staff, "Gene" Bonifacio Carlos, who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (2) clients present.

The facility is a one story home with (3) bedrooms and (2) bathrooms with attached garage, and a fenced pool. No firearms are being kept at the facility. The facility is an adult residential facility licensed for (4) ambulatory clients ages 18 to 59 years old. A citation was issued for both clients who are over the age of 60 with no exception on file for retention of the clients.

Infection Control: The LPA observed hand hygiene, personal hygiene supplies, PPE equipment, and cleaning supplies to do regular cleaning of the facility. A citation was issued for the facility not having an infection control plan for review during the visit.



Physical Plant: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. A citation was issued for the outdoor area which does not have furniture for clients. The sharp and dangerous objects were observed to be locked and inaccessible to clients in a pantry closet. The smoke detector and carbon monoxide was operational, and the hot water temperature 105F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2025
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 8
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BETA RESIDENTIAL HOME
FACILITY NUMBER: 330911397
VISIT DATE: 05/29/2025
NARRATIVE
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Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. Required postings were found in the facility. The administrator has been verified on the Community Care Licensing website for a renewal certificate which is pending review by the department. Denial of the application may result in future deficiencies.

Record Review and Resident/Staff Files: LPA reviewed (3) staff files and training. All staff have criminal clearance. Citations were issued for (1) staff who does not have updated CPR and first aid training, and does not have documented health screening and TB test. A citation was issued for the administrator's file which was not available for review at the time of the visit. (2) client files were reviewed. A citation was issued for (1) client who did not have signed personal rights form on file. LPA reviewed the personal and incidental funds and ledgers which were up to date and accurate.

Health Related Services/ Incidental Medical Services: All client medication was locked in the facility kitchen. LPA reviewed client medications for clients and found all medication listed on Medication Administration Records (MAR) and all medications kept in the originally received containers with required labeling.

Disaster preparedness: A citation was issued for the facility's emergency and disaster plan which is not accurate and updated to include staff working at the facility and include an evacuation procedure and plan for being self sufficient for 72 hours. LPA reviewed documentation showing the facility's last drill 05/04/2025, which met the department requirements. LPA observed all facility exits were clear from obstructions.

An exit interview was conducted where this report along with LIC809 pages, and appeal rights were reviewed and provided.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 05/29/2025 05:29 PM - It Cannot Be Edited


Created By: Janira Arreola On 05/29/2025 at 03:38 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: 05/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
80066 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: This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with the Administrator's file which was not at the facility for licensing review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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The licensee is to send the LPA a copy of their file to review. The licensee is to submit an updated staff schedule showing increased number of hours at the facility for the administrator in order to audit and inspect facility records for completion. Both items must be submitted by the POC date.
Type B
Section Cited
CCR
80065(g)(1)
80065 Personnel Requirements (g) All personnel…shall be in good health, and shall be…capable of performing assigned tasks. (1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician…This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review the licensee did not comply with the section cited above with (1) staff who did not have a completed and signed health screening or TB test which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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The licensee is to have the staff complete the physical and TB test and send LPA a copy for review. The licensee is to submit an updated staff schedule showing increased number of hours at the facility for the administrator in order to audit and inspect facility records for completion. Both items must be submitted by the POC 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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Janira Arreola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/29/2025 05:29 PM - It Cannot Be Edited


Created By: Janira Arreola On 05/29/2025 at 04:00 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: 05/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(g)
85068.4 Acceptance and Retention Limitations (g) If…retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients…the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above with (2) of (2) residents who are over the age of 60 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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The licensee is to submit an exception request to retain the resident in accordance with the section cited above and submit this by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Janira Arreola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/29/2025 05:29 PM - It Cannot Be Edited


Created By: Janira Arreola On 05/29/2025 at 04:36 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: 05/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
85087.2(b)
(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
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Based on observation and interview, the licensee did not comply with the section cited above with outdoor seating avauible for client during the time of the visit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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The licensee is to have seating avaible for clients in the outdoor area and send proof of correction by the 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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Janira Arreola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 05/29/2025 05:29 PM - It Cannot Be Edited


Created By: Janira Arreola On 05/29/2025 at 04:36 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: 05/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in with (1) staff who does not have updated CPR and first aid training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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The licensee is to submit updated CPR and first aid training for the staff by the POC due date.
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review the licensee did have an accurate and up to date emergency and disaster plan which poses a potential health saftey or personal rights risk to clients in care.
POC Due Date: 06/27/2025
Plan of Correction
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 The licensee is to submit an updated emergency and disaster plan with designated staff, evactuation plan, and 72 hour plan to be self sufficient by the 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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Janira Arreola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2025


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 05/29/2025 05:29 PM - It Cannot Be Edited


Created By: Janira Arreola On 05/29/2025 at 04:53 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: 05/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(d)
80072 Personal Rights (d) At admission, a client and the client's authorized representative shall be personally advised of and given a list of the rights specified in Sections 80072…This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review the licensee did not comply with the section cited above with (1) client who did not have a signed personal rights form on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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The licensee is to submit a signed personal rights form for the resident or their responsible party by the POC due date.
Type B
Section Cited
CCR
85095.5(c)(1)(D)
85095.5 Infection Control Requirements (c) An Infection Control Plan shall be developed by the licensee...(1) The Infection Control Plan shall include...(D) The licensee shall review the use of infection control procedures in the facility at least annually...or if the review is requested by the local licensing agency. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above with the infection control plan that was not available for review during the time of the visit and staff stating they have not know what an infection control plan was which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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The licensee is to submit the infection control plan for review and document its review with facility staff by the 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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Janira Arreola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2025


LIC809 (FAS) - (06/04)
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