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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336408324
Report Date: 10/07/2024
Date Signed: 10/07/2024 04:13:59 PM

Unsubstantiated


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
10/04/2024 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20241004105831
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: 2DATE:
10/07/2024
UNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Kathleen Davis, CaregiverTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility food supply is inadequate.
INVESTIGATION FINDINGS:
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On 10/07/24 Licensing Program Analysts (LPAs) Debbie Palacios, Armando Perez, and Javina George made an unannounced visit to the facility to commence a complaint investigation in regards to the allegation listed above. LPAs met with Caregiver Kathleen Davis and Administrator Mary Martin who was available via telephone and explained the purpose of the visit and the elements of the allegation. The allegation were investigation, the investigation consisted of observations, interviews and records reviews. On 10/04/24 Community Care Licensing received a complaint alleging the facility food supply is inadequate.

LPAs observed for the facility’s food supply to meet the requirement of having a 2-day supply of perishable and a 7-day supply of nonperishable food items. The facility was observed to have menus posted from July/August 2024, snacks are offered if the clients want them, such as chips or cake. Per interviews with staff the menus are not necessarily followed, and staff choose what the meals will be for the day based on what ingredients the home has. In addition, staff interviewed denied having to bring food items from home or having to purchase the items themselves that the home needs.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 18-AS-20241004105831
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: 10/07/2024
NARRATIVE
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Shopping is done once a month, usually around the 15th and when items such as milk, bread and eggs run out, then the Administrator Martin will go and purchase the items that are needed. Per interviews with clients, there are not any concerns with the food supply, as they stated that they are served 3 meals a day. (C1) reported that they are served snack and (C2) stated that they did not have snack. Based on observations and interviews. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.

An exit interview was conducted and a copy of this report 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
LIC9099 (FAS) - (06/04)
Page: 4 of 5