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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408324
Report Date: 10/07/2024
Date Signed: 10/07/2024 04:16:41 PM

Document Has Been Signed on 10/07/2024 04:16 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/
DIRECTOR:		MARY MARTINFACILITY TYPE:
735
ADDRESS:13155 BAGATELLE STREETTELEPHONE:
(951) 656-0366
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 5CENSUS: 2DATE:
10/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Kathleen Davis, Caregiver TIME VISIT/
INSPECTION COMPLETED:
04:25 PM
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On 10/07/24 Licensing Program Analysts (LPAs) Debbie Palacios, Armando Perez, and Javina George made an unannounced case management deficiencies visit to the facility.

During today's visit the following deficiencies were observed:

Food supply: While checking the food supply the expired food (2) cans of split peas, cream of wheat, (3) packages spaghetti noodles, pasta, and a can of biscuits. A total of 13 items in total, some of them are expired back in December 2023.

Reporting requirements: LPAs were informed of an incident that occurred on or around 9/21/24 of a verbal altercation that was had between staff and a client that resulted in law enforcement having to respond to the facility and the staff being terminated. The department did not receive an incident report regarding the incident.

Medication: The medications were observed to be locked and inaccessible to clients in care. While taking a tour of the facility LPA George observed for there to be dispensed medication (1 oval capsule) found on the bedroom floor.

Administrator Martin agreed to bring an updated LIC9020-Client roster, LIC500-Personnel report and Personal and Inventory (P&I) to the upcoming office meeting.

An exit interview was conducted and a copy of this report, appeal rights, LIC9098--proof of corrections form was provided to Caregiver Kathleen Davis.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024
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 3
Document Has Been Signed on 10/07/2024 04:16 PM - It Cannot Be Edited


Created By: Javina George On 10/07/2024 at 02:23 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: 10/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2024
Section Cited
CCR
80076(a)(1)

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Food Service (a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily
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times, which poses a potential health safety and personal rights risk to persons in care. There is no POC due as the items were discarded at the time of LPAs visit.
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Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: the expired food items (peas, biscuit, spaghetti noodles, pasta). the Licensee did not ensure to dispose of expired food items 14 out 14
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Type B
10/21/2024
Section Cited
CCR80061(b)

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Reporting requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report
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personal rights risk to persons in care.

The licensee agrees to conduct an inservice on reporting requirements. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. This requirement is not met as evidenced by: the licensee did not ensure to report an incident 1 out of times this posed a potential health safety and
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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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/07/2024 04:16 PM - It Cannot Be Edited


Created By: Javina George On 10/07/2024 at 02:44 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: 10/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2024
Section Cited
CCR
80075(k)(1)

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Health Related Services (k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This
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The licensee agrees to conduct an inservice on medication administration. Proof is to be submitted to the department by 5pm on the due date indicated.
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requirement is not met as evidenced by: there was an oval shaped capusle found on the floor inside the vacant bedroom. This posed a potential health safety and 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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


LIC809 (FAS) - (06/04)
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