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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408324
Report Date: 11/05/2024
Date Signed: 11/05/2024 03:57:04 PM

Document Has Been Signed on 11/05/2024 03:57 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:
11/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Kathleen DavisTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analysts (LPAs),Abdoulaye Zerbo and Armando Perez conducted an unannounced visit to the facility for a health an safety check. The LPAs met with caregiver Kathleen Davis, and informed her of the purpose for the visit and were granted access.

The facility is a single story building and consists four (4) resident bedrooms and two (2) bathrooms. There are currently two (2) residents in care. LPAs toured the facility for the purpose of a health and safety check. LPAs observed eleven(11) out of twelve(12) items to be expired in the emergency backpack. A citation will be issued. LPAs observed the licensee not to have a current administrator's certificate. A citation will be issued.

LPAs were not able to obtain the LIC 500 and LIC 9050 as the facility did not have them on site. A citation will be issued. LPAs observed current personnel to be fingerprint cleared and listed on the facility's personnel report.

An exit interview was conducted, and a copy of this report was provided to caregiver Kathleen Davis.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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 2
Document Has Been Signed on 11/05/2024 03:57 PM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 11/05/2024 at 02:24 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: 11/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2024
Section Cited
HSC
85066(b)(1)(2)(3)(4)

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85066 Personnel Records

(b) A dated employee time schedule shall be developed at least monthly, shall be displayed conveniently for employee reference and shall contain the following information for each employee:

(1) Name.

(2) Job title.

(3) Hours of work.

(4)Days off.
This requirement is not met as evidenced by:
Based on observation and interview, the licensee did not comply with the section cited above in one of one file, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Licensee agreed to send proof of personel roster by POC due date.
Type B
11/12/2024
Section Cited
HSC
87555(b)(6)

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87555 General Food Service Requirements
(b) The following food service requirements shall apply:
(6) In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Facilities licensed for less than sixteen (16) residents shall maintain a sample menu in their file. Menus shall be made available for review by the residents or their designated representatives and the licensing agency upon request.
This requirement is not met as evidenced by:
Based on observation and interview, the licensee did not comply with the section cited above in eleven(11) of twelve(12) can food to be expired in the emergency backpack, which poses/posed a potential health, safety or personal rights risk to persons in care.

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LPAs observed licensee replacing the expired food in the emergency backpack
Type B
12/05/2024
Section Cited
HSC85064.2(h)

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85064.2 Administrator Certification Requirements
(h) Certificates shall be valid for a period of two (2) years and expire on either the anniversary date of initial issuance or on the individual's birthday during the second calendar year following certification.
This requirement is not met as evidenced by:
Based on observation and interview and record review, the licensee did not comply with the section cited above in one of one administrator's certificate to be expired, which poses/posed a potential health, safety or personal rights risk to persons in care.


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Licensee will send a proof of recertification by the POC due date

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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:Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


LIC809 (FAS) - (06/04)
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