336408324-8-9-2023-18-AS-RSTS-CXP3R7-20231117172816

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336408324
Report Date: 08/09/2023
Date Signed: 08/09/2023 03:38:24 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/08/2023 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230808095604

FACILITY NAME:	EPSILON RESIDENTIAL HOME		FACILITY NUMBER:	336408324
ADMINISTRATOR:	MARY MARTIN		FACILITY TYPE:	735
ADDRESS:	13155 BAGATELLE STREET		TELEPHONE:	(951) 656-0366
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92553
CAPACITY:	5	CENSUS: 2	DATE:	08/09/2023
		UNANNOUNCED	TIME BEGAN:	11:31 AM
MET WITH:	Armando Aguilar, Staff		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Illegal Eviction
Staff refused medical treatment for client in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Jesse Gardner, conducted an unannounced visit to the facility to initiate an investigation into the above allegations. LPA met with Staff Armando Aguilar, explained the purpose of the visit, and conducted a tour of the facility.

LPA conducted interviews with residents, staff, and reviewed documentation provided to the Department as well as conducted a review of facility records.

It was alleged that a 3-day eviction was issued to Client #1 (C1) on 7/28/2023, and did not meet the criteria for a valid eviction per Title 22. Based upon a review of the letter, it was determined that the eviction notice was not in compliance with Title 22 regulation.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20230808095604

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: EPSILON RESIDENTIAL HOME	FACILITY NUMBER: 336408324
	VISIT DATE: 08/09/2023

NARRATIVE

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The reason for the eviction did not meet the criteria for eviction as stated in Title 22 regulations. Additionally, the eviction letter did not identify available resources to assist the resident and/or family in finding alternative housing and the letter was not submitted to Licensing, as required. Thus, this allegation was Substantiated.

It was then alleged that Client #2 (C2) needed to be seen by a medical professional on 8/8/2023, and was not provided the opportunity to by the Licensee. LPA conducted interviews with clients, the Licensee, and conducted a record review of the facility's Program Design. Licensee interview revealed that C2 advised the Licensee that they were in a great amount of physical pain at approximately 9:00am. Licensee as well as clients confirmed that a hospital visit was not offered by the Licensee to C2, instead, Licensee stated that a tele-health appointment was made with C2's doctor on 8/9/2023 at 3:15pm for C2. Due to C2 voicing the need to be seen by a medical professional for their complaint of pain, and was denied the immediate care, this allegation was Substantiated.

Based on interviews and documents obtained, and reviewed, the preponderance of evidence standard has been met and the allegations are SUBSTANTIATED. California Code of Regulations, Title 22, is being cited on the attached LIC9099D.

An exit interview was conducted where a copy of this report, LIC811, LIC9099D, and appeal rights were discussed and provided to the Licensee.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20230808095604

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: EPSILON RESIDENTIAL HOME	FACILITY NUMBER: 336408324
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/16/2023 Section Cited CCR 80068.5(b)(1)	1 2 3 4 5 6 7	Eviction Procedures: (b)The licensee shall obtain prior written approval from the Department to evict the client upon three (3) days written notice to quit and upon a finding of good cause.(1)Good cause exists if the client engages in behavior that threatens the mental and/or physical health or safety of himself/herself or others in the facility. This requirement was not being met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to rescind the Eviction notice, submit a written statement of understanding of Title 22 regulation cited and the importance of providing a lawful eviction notice. Proof of POC to be submitted by 8/16/2023.
	8 9 10 11 12 13 14	Based on Licensee interview, a 3-day eviction was issued to C1 on 7/28/23 and notice of the eviction was not sent to CCL as required by Title 22. This poses a potential personal rights risk to clients in care.	8 9 10 11 12 13 14
Type B 08/16/2023 Section Cited CCR 80075(a)	1 2 3 4 5 6 7	Health Related Services: (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement was not being met as evidenced by:	1 2 3 4 5 6 7	Licensee advised a medical appointment was scheduled for 8/9/23 at 3:15pm to treat C2. Licensee further agrees to conduct in-service training on the cited regulation by the POC date.
	8 9 10 11 12 13 14	Based on LPA interview with Licensee and clients, LPA determined that C2 was not given an opportunity to have the neccessary medical attention that C2 required. This is a potential health and safety risk to clients in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC9099 (FAS) - (06/04)

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