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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408324
Report Date: 08/09/2023
Date Signed: 08/09/2023 03:39:37 PM

Document Has Been Signed on 08/09/2023 03:39 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:
08/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Armando Aguilar, StaffTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Jesse Gardner, conducted an unannounced visit to the facility to initiate an investigation, refer to (18-AS-20230808095604). LPA met with Staff Armando Aguilar (S1), explained the purpose of the visit, and conducted a tour of the facility.

Upon review of records, LPA found that S1 did not have a background clearance.

Concluding interviews with staff, and clients, an immediate Civil Penalty of $100/day will apply for a total of 2 days at $200 as interview with Licensee verifed S1 has spent time supervising clients inside the facility the past two days (8/8/23, and 8/9/23). The following violation is cited under Title 22 Division 6 Chapter 1 section 80019(e)(1). LPA observed S1 leave the facility.

An exit interview was conducted and a copy of this report was discussed with and provided along with with copies of the LIC809D, LIC421BG, and Appeal Rights.
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.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/09/2023 03:39 PM - It Cannot Be Edited


Created By: Jesse Gardner On 08/09/2023 at 02:02 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: 08/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/10/2023
Section Cited
CCR
80019(e)(1)

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Criminal Record Clearance:
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department or..This requirement was not being met as evidenced by:
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Licensee agrees to conduct in-service training on the cited regulation and provide to LPA by POC date. Additionally, Licensee agrees that S1 will leave the facility until S1 obtains a clearance.
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Based on record review, and interview, LPA found that S1 did not have a background clearance to provide care/supervision to clients in care. This poses an immediate health and safety 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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