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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408324
Report Date: 05/08/2023
Date Signed: 05/08/2023 05:56:11 PM

Document Has Been Signed on 05/08/2023 05:56 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:MARY MARTINFACILITY TYPE:
735
ADDRESS:13155 BAGATELLE STREETTELEPHONE:
(951) 656-0366
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 5CENSUS: 2DATE:
05/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Kathy Davis, CaregiverTIME COMPLETED:
06:05 PM
NARRATIVE
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On 5/8/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced to the facility to conduct a case management visit regarding a Special Incident report received on 5/3/2023 stating Resident #1 (R1) was stabbed in the head while outside the home. LPA met with Caregiver, Kathy Davis who was informed of the purpose of the visit.

LPA toured the facility inside and out with Kathy Davis, interviewed staff and reviewed resident file. LPA was informed R1 was taken to the hospital for medical assistance and has since been back at the home.

During interview with staff, LPA was informed that R1 is independent and goes out to the community without supervision. LPA reviewed R1’s file, file review revealed no documentation that shows R1 is independent, no documentation showing an appraisal was performed prior to R1’s admission into the facility, no medical assessment documentation, no Needs and Services Plan developed for R1. Facility also failed to report to the department each time R1 left the facility unsupervised.

Therefore, based on the observations made during today’s visit, two #2 citations will be issued per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted, and this reported was provided along with appeal rights to Kathy Davis.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2023
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 05/08/2023 05:56 PM - It Cannot Be Edited


Created By: Chinwe Nwogene On 05/08/2023 at 05:21 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: 05/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2023
Section Cited
CCR
85068.1(b)

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Admission Procedures;
(a) The licensee shall develop, maintain, and implement admission procedures which shall meet the requirements specified in this section.
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Kathy stated a proof of appraisal done for R1, Mental Health Intake Assessment, Needs and Services Plan will be provided to LPA by the POC due date 5/17/2023.
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This requirement is not met based as evidence by observation, interview, and record review. The licensee did not comply by not having an appraisal done for R1, Mental Health Intake Assessment, Needs and Services Plan prior to R1 admission into the facility which poses a potential health, safety or personal rights risk to persons in care.
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Type B
05/17/2023
Section Cited
CCR80061(a)

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Reporting Requirements
(a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department.
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Kathy stated moving forward the facility will report to the department each time the resident leaves the facility without supervision and a written understanding of the regulation cited above will be provided to LPA by the POC due date 5/17/2023.
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This requirement is not met based as evidence by observation, interview, and record review. The licensee did not comply by not reporting to the department each time R1 left the facility unsupervised which poses a potential health, safety or personal rights risk to persons 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.
SUPERVISOR'S NAME:Joel Esquivel
LICENSING EVALUATOR NAME:Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023


LIC809 (FAS) - (06/04)
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