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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408324
Report Date: 02/14/2025
Date Signed: 02/14/2025 09:13:18 AM

Document Has Been Signed on 02/14/2025 09:13 AM - 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: 1DATE:
02/14/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:40 AM
MET WITH:Staff, Inarcidye AstrileTIME VISIT/
INSPECTION COMPLETED:
09:20 AM
NARRATIVE
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Licensing Program Analysts (LPA)’s Janira Arreola and Abdoulaye Zerbo, conducted an unannounced visit to the facility to conduct a Plan of Correction (POC) Visit. The purpose of this report is to document the POCs that were previously agreed upon. LPAs met with Staff, Inarcidye Astrile who was informed of the purpose of the visit. LPAs conducted a walk through, conducted interviews and records review.

During Annual Visit conducted on 9/26/2024 the facility was cited for California Code of Regulations (CCR) Section 85095.5(b) for not having an infection control plan. The POC was to submit proof of Infection Control Plan by the POC due date of 10/18/2024.



During Case Management Visit conducted 10/7/2024 the facility was cited for CCR 80061(b) for not reporting incidents occurring to clients. The POC was to conduct an in-service on reporting requirements and submit proof by POC due date 10/21/2024.

During Case Management Visit conducted 10/7/2024 the facility was cited for 80075(k)(1) lose medication on the floor of a client room, The licensee agreed to conduct an in-service on medication administration and submit proof by POC due date 10/21/2024.

During Case Management Visit conducted 11/5/2024 the facility was cited for 85066(b) for not having a personnel roster. Licensee agreed to send proof of personnel roster by POC due date 11/12/2024.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/14/2025
NARRATIVE
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LPAs attempted to conducted a mandated unannounced visit on 2/11/2025 at 8:40am and 3:50pm.LPAs contacted the Licensee who stated there were no staff available to meet the LPAs.

A second attempt was conducted on 2/13/2025 at 8:40am where LPAs were denied entry by an unknown uncleared person who identified themselves as Person 1 (P1). P1 stated they were not a staff member and there were no other people in the home at that time. They also reported that the Licensee instructed them not to let anyone enter the home and denied the LPAs entry. LPAs further observed at 9:15am (3) individuals coming out of the home who were unable to be identified as they covered their faces as they exited the home. LPAs contacted the Licensee who denied knowing P1 and denied instructing P1 not to let LPAs into the home. At 9:58am, LPAs attempted another visit, as the Licensee had stated a staff member Staff #1 (S1) was at the home, however when LPAs attempted entry and attempted to contact S1 and the Licensee LPAs received no answer.

The Licensee stated S1, Staff #2 (S2), and Staff #3 (S3) are working at the home, however none of the staff are on the Guardian roster.

Therefore, the licensee is being cited for denying entry to LPAs, an immediate civil penalty of $500 is being issued along with a citation. The Licensee is being cited for lack of supervision and staff presence, an immediate civil penalty of $500 is being issued along with a citation. The Licensee is also being cited for S1, S2, S3 and the (3) unidentified individuals who LPAs witnessed exiting the home, civil penalties are being assessed for all (6) individuals at $500.

During today’s visit it was confirmed with the Licensee Mary Martin over the phone, that the agreed upon POCs had not been submitted to the department by the POC due dates and had not been met. The time frame for POC inspection has lapsed, therefore the deficiencies will be re-cited on this report along with a new POC due date.

LPAs were unable to stay at the facility and deliver a report due to strong penetrated odor in the home that caused LPAs headache and nausea. LPAs encountered a client who made threats, used foul language, racial slurs, and yelled at LPAs. Staff present was unable to redirect the client. LPAs were able to conduct a walk through before leaving the home.

An exit interview was conducted with Mary Martin over the phone where this report along with the LIC809D page, and appeal rights were reviewed and provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/14/2025 09:13 AM - It Cannot Be Edited


Created By: Janira Arreola On 02/14/2025 at 07:29 AM
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: 02/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2025
Section Cited
CCR
85095.5(b)

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(b) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. This requirement is not met as evidenced by:
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POC is to submit a complete infection control plan that meets department requirements by the POC due date.
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Based on interview and record review, the licensee did not comply with the section cited above in having an Infection Control Plan available for review during LPA's inspection which posed a potential health, safety, or personal rights risk to clients in care.
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Type B
02/17/2025
Section Cited
CCR80061(b)

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(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below…a written report 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:
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POC is to conduct an in-service on reporting requirements and submit proof of training and staff trained by the POC due date.
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Based on interview the licensee did not report an incident of a verbal altercation between staff and client where law enforcement had to respond to the facility. This posed a potential health safety and 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.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 02/14/2025 09:13 AM - It Cannot Be Edited


Created By: Janira Arreola On 02/14/2025 at 07:31 AM
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: 02/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2025
Section Cited
CCR
80075(k)(1)

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80075(k)(1) (k) The following requirements shall apply…(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 requirement is not met as evidenced by:
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POC is to conduct an in-service on medication administration and proper storage. Proof of training conducted and staff trained is due by POC due date.

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Based on observation an oval shaped capsule was found on the floor inside a vacant bedroom. This posed a potential health safety and personal rights risk to persons in care.
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Type B
02/17/2025
Section Cited
CCR85066(b)

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(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:
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POC is to send proof of personnel roster by POC due date.
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Based on observation and interview, the licensee did not have a personnel roster which poses a potential health, safety or 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.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 02/14/2025 09:13 AM - It Cannot Be Edited


Created By: Janira Arreola On 02/14/2025 at 07:33 AM
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: 02/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/15/2025
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision

(a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirment was not met as evidenced by:
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The POC is to provide a personnel roster showing staff coverage at all times by the POC due date.
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Based on observation and interview the licensee did not have staff present at the facility on 2/1/2025. This poses an immediate health safety or personal rights risk to clients in care.
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Type A
02/15/2025
Section Cited
CCR80044(a)

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80044 Inspection Authority of the Licensing Agency (a) The licensing agency shall have the inspection authority specified in Health and Safety Code Sections 1526.5, 1533, 1534, 1538, and 1538.7. This requirment was not met as evidenced by:
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POC is for all staff including the licensee to attend a training on Licensing inspection authority by a Licensing approved vendor.
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Based on interview and observation LPAs were denied entry on 2/13/2025. This poses an immediate health saftey or personal rights risk to clients in care.
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Proof of scheduling the training is due and a written statement certifying that Licensing staff will be provided access to the home is due by the POC due date. Follow up proof to be sent when the training is completed.
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:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


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Page: 4 of 7
Document Has Been Signed on 02/14/2025 09:13 AM - It Cannot Be Edited


Created By: Janira Arreola On 02/14/2025 at 07:42 AM
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: 02/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/15/2025
Section Cited
CCR
80019(e)(2)

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(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) Submit a valid mailing address at which the individual shall receive communications from the Department.(2) Obtain a California clearance or a criminal record exemption as required by the Department or...
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POC is to remove the uncleared people from the home, and provide proof of fingerprinting S1, S2, and S3. All staff including the Licensee to attend training from an approved vendor on criminal record clearance.
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This requirment was not met as evidenced by: Based on observation and interview there were (3) uncleared people in the home 2/13/2025, and (3) staff working who are not fingerprinted. This poses an immediate health saftey or personla rights risk to clients in care.
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Proof of enrollment is due by POC due date. Proof of completion to be sent to LPA.

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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:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 02/14/2025 09:13 AM - It Cannot Be Edited


Created By: Janira Arreola On 02/14/2025 at 08:31 AM
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: 02/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/15/2025
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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POC is for the Licensee to send certified statement that the home has been cleaned and no longer has malodor
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This requirement was not met as evidenced by: Based on LPAs experiencing the smell of the home during the visit where LPAs were unable to complete the visit. This posesa health saftey or 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.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


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