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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336408324
Report Date: 08/15/2023
Date Signed: 08/15/2023 12:50:49 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/31/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230731083041
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: 0DATE:
08/15/2023
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Mary Martin, LicenseeTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Air Conditioning not operable
Licensee not ensuring residents needs are met
Licensee not ensuring clients are attending activities
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Jesse Gardner, conducted an unannounced visit to the facility to deliver findings to the investigation into the above allegations. LPA met with Licensee Mary Martin, explained the purpose of the visit, and conducted a tour of the facility.

It was alleged that the A/C had been in disrepair since before the summer, 2023. The Clients were relocated to another home while the repair was being conducted. Interview with clients revealed that they moved out of the home on or about 7/28/2023, and Interview with Licensee revealed that Clients moved back into the home sometime during the week of 8/7/2023. Interview with Licensee revealed that as of 8/14/2023, the A/C had still not been fully repaired.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 18-AS-20230731083041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 336408324
VISIT DATE: 08/15/2023
NARRATIVE
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Interview with clients revealed that clients had been sleeping on the couch in the living room due to the level of heat that was in their bedrooms at night. During today's visit (8/15/2023), LPA observed the interior temperature to be at 75 degrees with operational fans. Due to the repair not being conducted in a reasonable time frame to keep the clients comfortable, this allegation was Substantiated. A citation was issued per Title 22.

It was then alleged that the Licensee was not able to meet client needs by not washing client clothes while they were relocated. Interview with staff at the facility that the clients relocated to, indicated that the washer had been broken, and was washing the clients clothes that resided there at their own residence, but had no information related to the clients who had relocated and the schedule to clean their clothes. Interview with the Licensee assumed that the clients who had relocated from Epsilon Residential to Beta Residential had their clothes clean. Based off of interview with staff and Licensee, LPA concluded that there was not a system in order to maintain that the clients needs were met; thus, this allegation was Substantiated. A citation was issued per Title 22.

It was then alleged that C1 had not been to day program on 7/31/2023. Interview with staff revealed that C1, due to relocating from Beta Residential to Epsilon Residential, had not had their shoes, and was wearing "flip-flops". Interview with staff, and clients revealed that staff told C1 that they would not be able to attend day program in flip-flops. Confidential Interview revealed that C1 is able to attend day program in flip-flops. Due to the Licensee not providing another resource for C1 to attend day program, this allegation was Substantiated. A citation was issued per Title 22.

An exit interview was conducted where a copy of this report was discussed and provided along with copies of the LIC811, LIC9099C, LIC9099D, and Appeal Rights.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20230731083041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 336408324
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2023
Section Cited
CCR
80072(a)(2)
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Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not being met as evidenced by:
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Licensee agrees to show proof of A/C repair and provide to CCL by POC date. Additionally, Licensee agrees to conduct in-service training to all staff regarding the cited regulation by POC date.
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Based on Interview with Licensee, LPA found that the clients were in the home when the A/C was in a state of repair and not working properly enough to allow them access to sleep in their own beds. This poses an immediate personal rights risk to clients in care.
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Type B
08/29/2023
Section Cited
CCR
80072(a)(2)
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Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.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 proof of such to all staff by POC date.
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Based on interview with Licensee, Licensee did not have a plan for residents when they relocated to another facility to keep their clothes clean. This is a potential 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.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20230731083041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 336408324
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2023
Section Cited
CCR
80072(a)(3)
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Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. 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 proof of such to all staff by POC date.
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Based on interview with Licensee, Licensee thought that C1 was not able to attend day program in flip-flops, and therefore did not provide a means to C1 to attend. This is a potential 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.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4