<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408324
Report Date: 05/26/2022
Date Signed: 05/26/2022 10:15:14 AM

Document Has Been Signed on 05/26/2022 10:15 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:EPSILON RESIDENTIAL HOMEFACILITY NUMBER:
336408324
ADMINISTRATOR:MARY MARTINFACILITY TYPE:
735
ADDRESS:13155 BAGATELLE STREETTELEPHONE:
(951) 656-0366
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 5CENSUS: 3DATE:
05/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Pam Lyles, AdministratorTIME COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jesse Gardner was inside the facility investigating complaint #18-AS-20220517104629.

LPA noted that a Caregiver Dolores Raygoza to not have a fingerprint clearance with Guardian. Ms. Raygoza explained that she had been working inside the facility for approximately 2 years. providing care to residents. LPA found that per Guardian, Ms. Raygoza's clearance is "In Process". Thus an immediate $500 civil penalty was issued.

Administrator Lyles explained that they had submitted the clearance approximately 30 days ago, and will follow up with Guardian in relation to the clearance. LPA witnessed Ms. Raygoza leave the facility. LPA explained to Ms. Lyles that Ms. Raygoza is not to return working until the clearance is complete.

An exit interview was completed, and this report was discussed with and a copy was provided along with copies of the LIC421BG, and Appeal Rights.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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 2
Document Has Been Signed on 05/26/2022 10:15 AM - It Cannot Be Edited


Created By: Jesse Gardner On 05/26/2022 at 09:38 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: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/27/2022
Section Cited
CCR
80019(e)(1)

1
2
3
4
5
6
7
CRIMINAL RECORD CLEARANCE:(e)All individuals subject..prior to..
(1) Obtain a California clearance or a criminal record exemption..This requirement was not being met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to remove S1 from the property until a clearance is obtained, and submit a memorandum of understanding of the regulation by POC date.
8
9
10
11
12
13
14
Based on LPA's record review, the Licensee did not comply with the regulation by ensuring that S1 had a clearance prior to working inside of the faciltiy.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Deborah Mullen
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2