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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408324
Report Date: 03/07/2024
Date Signed: 03/07/2024 03:50:38 PM

Document Has Been Signed on 03/07/2024 03:50 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: 1DATE:
03/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Luther Armstrong - CaregiverTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of following up on past due licensing fees. LPA Colvin met with caregiver Luther Armstrong and informed him of the purpose of today's inspection. Below is a summary of the items discussed:

Licensing Fees: LPA Colvin observed that the facility has past due licensing fees in the amount of $1,362.00. Deficiency cited.

Certified Administrator: LPA Colvin observed that Mary Martin is listed as the facility's current Administrator, but her Administrator Certificate is expired as of 12/18/22. LPA Colvin additionally notes that the facility was cited for this during their annual inspection on 9/11/23 and has not been corrected, therefore, LPA Colvin will be re-citing a deficiency.

Criminal Background Clearance: LPA Colvin observed that caregiver Luke Armstrong (S1) is not associated to the facility. Deficiency cited. When there is staff present in the facility without having their criminal background clearance transferred to the facility, this results in a civil penalty of $100 per day for every day the individual is present at the facility, for a maximum of 5 days unless repeated within 12 months. Luke reports that he has been working at the facility for one month, therefore a civil penalty of $500 ($100 x 5) is being assessed today.

Based on observations made, the facility was cited and civil penalties were issued in the amount of $500. An exit interview was conducted with caregiver Luther Armstrong and a copy of this report, LIC809D, LIC421BG, and appeal rights were provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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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Document Has Been Signed on 03/07/2024 03:50 PM - It Cannot Be Edited


Created By: Crystal Colvin On 03/07/2024 at 03:35 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: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2024
Section Cited
CCR
80019(e)(3)

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Criminal Record Clearance: (e) All individuals ...shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f)... This requirement was not met by:
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Administrator states that she will associate S1 to the facility today. Administrator may self-certify to LPA Colvin once complete. Self-certification due 3/8/24.
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Based on record review and observation, the Licensee did not comply with the above regulation with one staff member (S1). LPA Colvin observed that S1 is not associated to the facility but has been working there for 1 month. This is an immediate safety risk to resdients in care.
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Type B
03/21/2024
Section Cited
CCR85064(b)

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Adminstrator Qualifications and Duties: (b) All adult residential facilities shall have a certified administrator. This requirement was not met as evidenced by:
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Licensee agrees to hire an Administrator with an active Administrator Certificate. Licensee to associate new Administrator and submit paperwork to Licensing to have them updated as Administrator by Plan of Correction date of 3/21/24.
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Based on interview and record review, the Licensee did not comply with the above regulation. The facility does not currently have an Administrator with an active Administrator Certificate. This poses a potential personal rights risk to residents 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:Rikesha Stamps
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/07/2024 03:50 PM - It Cannot Be Edited


Created By: Crystal Colvin On 03/07/2024 at 03:40 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: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2024
Section Cited
CCR
80036(a)

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LICENSING FEES: (a) An applicant or a licensee shall be charged fees as specified in Health and safety Code Section 1523.1. This requirement was not met as evidenced by:
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Administrator states that she will pay the licensing fees due. Licensee may sefl-certify to LPA Colvin once complete. Self-certification due by Plan of Correction date of 3/21/24.
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Based on record review, the Licensee did not comply with the above regulation with $1,362.00 of past due licensing fees. This poses a potential safety risk to residents in care as the license may be revoked.
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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:Rikesha Stamps
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
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