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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408324
Report Date: 01/09/2026
Date Signed: 01/09/2026 11:02:21 AM

Document Has Been Signed on 01/09/2026 11:02 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
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:
01/09/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:18 AM
MET WITH:Staff, Maribel AguilarTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Janira Arreola and Imaculada Vasquez, conducted an unannounced visit to the facility in order to conduct a case management visit. LPAs spoke to Licensee, Mary Martin over the phone during the visit. LPAs conducted interviews, records review and walk through during the time of the visit.

LPAs conducted a health and safety check on clients in care, however no clients were present at the time of the visit. Client was out in the community at the time of the visit. No immediate health or safety issues were observed during the visit, however the following violations were observed as potential risks:

LPAs observed (1) of (4) bedrooms did not have required furniture such as bed, night stand, and working lamp. LPAs observed all (4) rooms had no light bulbs or lighting the rooms. LPAs conducted a records review for client and found the client does not have a current admission agreement, this deficiency was previously cited on 09/29/2025, however the plan of correction has not been received at this time, there a new citation and plan of correction will be issued on this date.

The file review of the facility revealed outstanding annual licensing fees in the amount of $681.00. The licensee agreed to pay the fees by 01/16/2026. An exit interview was conducted where this report, appeal rights, plans of correction, and deficiencies were reviewed with the staff. A copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2026
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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Document Has Been Signed on 01/09/2026 11:02 AM - It Cannot Be Edited


Created By: Janira Arreola On 01/09/2026 at 10:30 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: EPSILON RESIDENTIAL HOME
FACILITY NUMBER: 336408324

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2026
Section Cited
CCR
80068(a)

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(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.This requirement is not met as evidenced by:
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The licensee stated they would submit the admission agreement for the client 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 with (1) client who did not have an admission agreement on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
01/16/2026
Section Cited
HSC1523.1(e)

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Health and safety Code Section 1523.1.(e)The failure of an applicant or licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement was not met as evidenced by:
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The licensee agreed to pay the feed by the POC due date and submit proof.
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Based on records review and interview their is an balance of $681.00 owed to the department in licensing fees. This poses a potential health, safety or 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.
Carolyn Tuba
NAME OF LICENSING PROGRAM MANAGER:
Janira Arreola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/09/2026 11:02 AM - It Cannot Be Edited


Created By: Janira Arreola On 01/09/2026 at 10:40 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: EPSILON RESIDENTIAL HOME
FACILITY NUMBER: 336408324

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2026
Section Cited
CCR
85088(c)

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85088 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. This requirement was not met as evidenced by:
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The licensee agreed to furnish the room with the required furniture as outlined in the section cited, and obtain light bulbs foe all rooms and submit proof of completion by the POC due date.
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Based on observation and interview the facility did not have lighting in the client rooms and (1) room did not have the required furniture. This poses a potential health safety or 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.
Carolyn Tuba
NAME OF LICENSING PROGRAM MANAGER:
Janira Arreola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2026


LIC809 (FAS) - (06/04)
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