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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408324
Report Date: 04/25/2025
Date Signed: 04/25/2025 04:10:24 PM

Document Has Been Signed on 04/25/2025 04:10 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:EPSILON RESIDENTIAL HOMEFACILITY NUMBER:
336408324
ADMINISTRATOR/
DIRECTOR:		MARY MARTINFACILITY TYPE:
735
ADDRESS:13155 BAGATELLE STREETTELEPHONE:
(951) 656-0366
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 5CENSUS: 1DATE:
04/25/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Licensee, Mary MartinTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola and Regional Manager Reyna Lacey met with the licensee, Mary Martin in office in order to follow up on Plan of Corrections (POCs) that were previously agreed upon. LPA conducted records review and interviews.

The facility was cited for California Code of Regulations (CCR) Section 85095.5(b) for not having an infection control plan. The POC was to submit proof of Infection Control Plan by the POC due date of 02/17/2025. The POC has not been received by the LPA.



The facility was cited for CCR 80061(b) for not reporting incidents occurring to clients. The POC was to conduct an in-service on reporting requirements and submit proof by POC due date of 02/17/2025. The POC has not been received by the LPA.

The facility was cited for 80075(k)(1) for lose medication on the floor of a client room, The licensee agreed to conduct an in-service on medication administration and submit proof by POC due date 02/17/2025. The POC has not been received by the LPA.
NAME OF LICENSING PROGRAM MANAGER: Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2025
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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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: EPSILON RESIDENTIAL HOME
FACILITY NUMBER: 336408324
VISIT DATE: 04/25/2025
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A deficiency was cited for 80063(a)(1) for not having an active governing body, as Community Valley Homes INC. is in a stated of forfeiture with the Franchise Tax Bureau (FTB). The licensee agreed to submit documentation showing good standing with the FTB by the POC due date of 02/17/2025. On today's date 04/25/2025 the FTB status is still showing in a state of forfeiture and the POC has not been met.

LPA attempted a visit on 02/20/2025, 4/1/2025, and 4/16/2025 but was unable to meet with the licensee due to licensee rescheduling meeting with LPA and LPAs being unable to access the facility. The time period to address to POC's has lapsed therefore the deficiencies are being recited and a new POC due date is being created.

A deficiency was cited for 85064(b) for not having a certified administrator, the licensee agreed to submit their renewal for Administrator’s certificate and designate a qualified administrator to the facility by the POC due date of 2/17/2025. Based on interview with licensee and record review of the Department's website pending renewal list for Administrator's Certificates, the licensee's renewal was received on 03/25/2025. Therefore, the POC has been met and the deficiency has been cleared.

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

NAME OF LICENSING PROGRAM MANAGER: Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/25/2025 04:10 PM - It Cannot Be Edited


Created By: Janira Arreola On 04/25/2025 at 01:28 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: EPSILON RESIDENTIAL HOME
FACILITY NUMBER: 336408324

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2025
Section Cited
CCR
85095.5(b)

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(b) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. This requirement is not met as evidenced by:
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POC is to submit a complete infection control plan that meets department requirements by the POC due date.
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Based on interview and record review, the licensee did not comply with the section cited above in having an Infection Control Plan available for review during LPA's inspection which posed a potential health, safety, or personal rights risk to clients in care.
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Type B
05/02/2025
Section Cited
CCR80061(b)

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(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below…a written report specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. This requirement is not met as evidenced by:
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POC is to conduct an in-service on reporting requirements and submit proof of training and staff trained by the POC due date.
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Based on interview the licensee did not report an incident of a verbal altercation between staff and client where law enforcement had to respond to the facility. This posed a potential health safety and 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.
Tricia Danielson
NAME OF LICENSING PROGRAM MANAGER:
Janira Arreola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 04/25/2025 04:10 PM - It Cannot Be Edited


Created By: Janira Arreola On 04/25/2025 at 01:30 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: EPSILON RESIDENTIAL HOME
FACILITY NUMBER: 336408324

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2025
Section Cited
CCR
80075(k)(1)

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80075(k)(1) (k) The following requirements shall apply…(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
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POC is to conduct an in-service on medication administration and proper storage. Proof of training conducted and staff trained is due by POC due date.
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Based on observation an oval shaped capsule was found on the floor inside a vacant bedroom. This posed a potential health safety and personal rights risk to persons in care.
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Type B
05/02/2025
Section Cited
CCR80063(a)(1)

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(a) The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and…its operation. (1) If the licensee is a corporation or an association, the governing body shall be active and functioning in order to ensure such accountability. This requirement was not met as evidenced by:
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The licensee agreed to send proof of good standing with the FTB and have an active governing body by POC due date.
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Based on interview and record review, the governing body is in a state of forfeiture and is not active as of 11/01/2024. This poses a potential health, safety, or personal rights risks 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.
Tricia Danielson
NAME OF LICENSING PROGRAM MANAGER:
Janira Arreola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2025


LIC809 (FAS) - (06/04)
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