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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336408324
Report Date: 02/14/2025
Date Signed: 02/14/2025 09:11:25 AM

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
02/05/2025 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20250205134815
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:
02/14/2025
UNANNOUNCEDTIME BEGAN:
07:40 AM
MET WITH:Staff, Inarcidye AstrileTIME COMPLETED:
09:20 AM
ALLEGATION(S):
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Facility does not have a certified Administrator
Governing body is not active
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA)’s Janira Arreola and Abdoulaye Zerbo, conducted an unannounced visit to the facility in order to investigate the above allegations. 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.

It was alleged “Facility does not have a certified Administrator”. LPAs conducted a review of the department’s current and pending list of Administrator’s Certificates and found none for the current administrator. LPA’s conducted a file review for the administrator and found there there was no certificate at the facility. LPAs conducted an interview with the administrator which revealed they submitted their qualifications to the department (2) months ago but did not have proof of the items sent.Therefore, based on interview and record review the allegation that the facility does not have a certified administer is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
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 3
Control Number 18-AS-20250205134815
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: 02/14/2025
NARRATIVE
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It was alleged that “Governing body is not active”, regarding the facility’s governing body being in a state of forfeiture with the Franchise Tax Bureau (FTB). LPAs conducted a file review which revealed the facility’s license is issued to entity Community Valley Homes INC. According to the Secretary of State website Community Valley Homes INC. has been in a state of forfeiture with the FTB as of 11/01/2024.

LPAs conducted an interview with the licensee which revealed their corporation is in good standing in the state of Nevada, but was unable to provide proof at the time of the visit. Therefore, based on interview and record review the allegation that the facility’s governing body is not active is substantiated.

Findings that are substantiated mean the preponderance of the evidence standard has been met. California Code of Regulations is being cited for the on the attached LIC 9099 D.

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 Licensee, Mary Martin over the phone and a copy of this report was emailed and mailed to the Licensee.

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
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20250205134815
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: 02/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2025
Section Cited
CCR
85064(b)
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(b) All adult residential facilities shall have a certified administrator. This requirement was not met as evidenced by:
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The licensee agreed to send proof of mailing their certificate's renewal and payment of the renewal by the POC due date. Licensee agreed to designate a qualified Administrator and send notification of the designation by the POC due date.
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Based on interview and record review the facility does not have a certified administrator at this time. This poses a potential health, safety, or personal rights risk to clients in care.
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Type B
02/17/2025
Section Cited
CCR
80063(a)(1)
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(a) The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and…its operation. (1) If the licensee is a corporation or an association, the governing body shall be active and functioning in order to ensure such accountability. This requirement was not met as evidenced by:
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The licensee agreed to send proof of good standing with the FTB and have an active governing body by POC due date.
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Based on interview and record review, the governing body is in a state of forfeiture and is not active as of 11/01/2024. This poses a potential health, safety, or personal rights risks 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: 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
LIC9099 (FAS) - (06/04)
Page: 2 of 3