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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408324
Report Date: 07/21/2022
Date Signed: 07/21/2022 11:26:03 AM

Document Has Been Signed on 07/21/2022 11:26 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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:
07/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Staff, Pamela LylesTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Janira Arreola made an unannounced visit to the facility for the purpose of a case management visit involving a recent death. LPA was greeted by staff, Pamela Lyles, who was informed of the purpose of the visit.

At the time of the visit, there was (2) staff member and (1) client present. LPA requested pertinent documented related to Client 1 (C1)'s death. LPA requested recent lab work, physician's report, ID and emergency contact, death report, daily client notes, and most recent IPP on file. Administrator was informed of documentation that would need to be faxed to the regional office as soon as possible. LPA also obtained a death summary of events leading up to C1's death from Administrator Mary Martin over telephone call.

LPA reviewed death report that staff, Pamela Lyles had attempted to faxed to the department on 7/18/2022. LPA will not issue deficiency for reporting requirements.

No Deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided to staff, Pamela Lyles.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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