<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336408324
Report Date: 08/15/2023
Date Signed: 08/15/2023 01:36:22 PM

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
05/17/2022 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220517104629
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:
08/15/2023
UNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Mary Martin, LicenseeTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility food service is inadequate.
Staff did not safeguard resident's personal items.
Resident is being bullied by other residents while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Jesse Gardner, conducted an unannounced visit to the facility to deliver findings to the investigation into the above allegations. LPA met with Licensee Mary Martin, explained the purpose of the visit, and conducted a tour of the facility.

It was alleged Client 1 (C1) had their food thrown out, while C1 was still eating. LPA conducted interviews with staff, and clients, and through those interviews, found that C1 had their food thrown out on several occasions while C1 was still eating. Thus, the allegation was Substantiated.

It was alleged that C1 had their money taken by another client while in care. Through
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
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 4
Control Number 18-AS-20220517104629
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: 08/15/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Interviews conducted with staff, and clients, LPA found that C1 had approximately $5.00 taken by another client. Client interviews revealed that staff knew about it and did nothing about it, and C1 was never returned their money. Thus, this allegation was Substantiated.

It was then alleged that C1 was bullied by other clients in care to clean their rooms. Interviews with staff and clients revealed that C1 was told to clean other clients rooms while they were gone at day program, or other occasions and C1 would clean. Thus, this allegation was Substantiated.

An exit interview was conducted and a copy of this report was discussed with and provided along with copies of the LIC811, LIC9099C, LIC9099D, and Appeal Rights.

*This is an amended report
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20220517104629
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: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2023
Section Cited
CCR
80072(a)(3)
1
2
3
4
5
6
7
Personal Rights: (a) Except for.. each client shall have personal rights which include, but are not limited to, the following:(3) To.. punishment, infliction of pain, humiliation,intimidation..mental..punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement was not being met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to conduct in-service training to all staff on the cited regulation and provide proof of such by POC date.
8
9
10
11
12
13
14
Based on client interviews, LPA found that C1's food was often taken from them before they could finish eating. This is a potential personal rights risk to clients in care.
8
9
10
11
12
13
14
Type B
08/29/2023
Section Cited
CCR
80072(a)(1)
1
2
3
4
5
6
7
Personal Rights: (a) Except for.. each client shall have personal rights which include, but are not limited to, the following:(1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not being met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to conduct in-service training with staff on the cited regulation and provide proof of such to LPA by POC date.
8
9
10
11
12
13
14
Based on interview with staff and clients, LPA found that C1 had $5 taken from them at some point. Interviews further indicated that the theft was known by staff, and nothing was done about it. This poses a potential personal rights risk to clients in care.
8
9
10
11
12
13
14
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: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20220517104629
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: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2023
Section Cited
CCR
80072(a)(1)
1
2
3
4
5
6
7
Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not being met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to conduct in-service training with staff on the cited regulation and provide proof of such to LPA by POC date.
8
9
10
11
12
13
14
Based on client interview, C1 was made to clean other client rooms. This poses a potential personal rights risk to clients in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4