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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408324
Report Date: 09/11/2023
Date Signed: 09/11/2023 01:16:25 PM

Document Has Been Signed on 09/11/2023 01:16 PM - 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 AC/SC, 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: 1DATE:
09/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tuwana Palmer - Administrative StaffTIME COMPLETED:
01:29 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with staff, Tuwana Palmer, who was informed of the purpose of the visit. At the time of the visit there was one (1) staff and zero (0) clients present.

The facility is a one story home with (4) bedrooms and (2) bathrooms with an attached garage. The clients served are adults between the ages of 18-59. LPA conducted a tour of the interior and exterior and reviewed facility documents. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility.



Physical Plant: Physical plant, floors, windows, and doors were observed to be clean. LPA observed the light switch in C1's room was not working. A deficiency will be issued. LPA observed a hole in the wall located in the living room. A deficiency will be issued due to the Physical Plant not being in good repair. The outdoor area was observed to be free of hazards and contains outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were not locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 118F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 09/11/2023 01:16 PM - It Cannot Be Edited


Created By: Sara Martinez On 09/11/2023 at 12:27 PM
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: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having an updated Administrators Certificate. LPA asked the Administrator about the submission for the administrators certificate and she stated the staff working at the main office should have submitted the check. LPA found that the Administrator did not submit the required documents in time to keep their certificate current. This poses an immediate health and safety risk to clients in care.
POC Due Date: 09/12/2023
Plan of Correction
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Licensee agrees to submit a plan to how their Administrator Certificate will be submitted by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Sara Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/11/2023 01:16 PM - It Cannot Be Edited


Created By: Sara Martinez On 09/11/2023 at 12:27 PM
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: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having a baseball size hole in the wall in the living room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2023
Plan of Correction
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Licensee will agree to fix the hole in the wall and will submit proof of repair to LPA by the agreed POC date.
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having the sharp knives and objects locked and inaccessible to the clients during LPA's visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2023
Plan of Correction
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Licensee will submit proof of having a locked drawer in the kitchen for the sharp object and knives so they will be inaccessible to the clients in care by the agreeded POC date.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Sara Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023


LIC809 (FAS) - (06/04)
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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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: EPSILON RESIDENTIAL HOME
FACILITY NUMBER: 336408324
VISIT DATE: 09/11/2023
NARRATIVE
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Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator does not have a current administrator's certificate. A deficiency will be issued.

Record Review and Resident/Staff Files: LPA reviewed three (3) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. One (1) client file were reviewed and possessed all required paperwork.



Health Related Services/ Incidental Medical Services: All client medication was locked in cabinet located in the kitchen. LPA reviewed client medications for (1) client and found all medication listed on MARS and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drill was conducted on 08/01/2023 which met the department requirements. LPA observed all facility exits were clear from obstructions.


An exit interview was conducted where a copy of this report was provided to Administrative Staff Tuwana Palmer.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/11/2023 01:16 PM - It Cannot Be Edited


Created By: Sara Martinez On 09/11/2023 at 12:56 PM
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: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(d)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having a working light switch in C1's room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2023
Plan of Correction
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Licensee agrees to replace and/or fix the light switch in C1's room and submit proof of repair to LPA by the POC date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Sara Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023


LIC809 (FAS) - (06/04)
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