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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408324
Report Date: 09/26/2024
Date Signed: 09/26/2024 01:40:50 PM

Document Has Been Signed on 09/26/2024 01:40 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:EPSILON RESIDENTIAL HOMEFACILITY NUMBER:
336408324
ADMINISTRATOR/
DIRECTOR:
MARY MARTINFACILITY TYPE:
735
ADDRESS:13155 BAGATELLE STREETTELEPHONE:
(951) 656-0366
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 5CENSUS: 2DATE:
09/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Kathleen Davis - Staff TIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA met with staff Kathleen Davis who was informed for the purpose of the visit and was granted entry. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. The following was observed:

Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were in good repair and were present. The outdoor area was observed to be free of hazards. The smoke detector and carbon monoxide was operational, and the hot water temperature met department requirements recorded at 111 and 117 degrees. Detergent and cleaning supplies were locked in a cabinet located under the sink. 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. Two (2) client files were reviewed during the inspection. Client One (C1) and Client Two (C2) did not have a current Physician's Report for review. A deficiency will be issued under Title 22 regulations 80069(b)(1) along with a plan of correction. LPA was not able to review C2's client records due to records were not complete, current, and maintained at the facility. A deficiency will be issued under Title 22 Regulations 80070(a) along with a plan of correction. LPA reviewed the facility's emergency and disaster plan. Facility did not have an infection control plan for LPA's record review. A deficiency will be issued under Title 22 Regulations 85095.5(c) along with a plan of correction. LPA observed emergency supplies in the garage and hallway closet and first aid kit with all required items. Client medication was centrally stored and locked in a medication cabinet located in the kitchen. LPA reviewed medications prescribed to one (1) client and found all medication with required labeling found to be in place. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator Mary Martin does not possess a current administrator's certificate. A deficiency under Title 22 regulation 85064(b) and a Civil Penalty will be issued along with a plan of correction.



An exit interview was conducted where a copy of this report, LIC 809-D, LIC 811, Civil Penalty Assessment, and Appeal Rights was provided to Kathleen Davis
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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 3
Document Has Been Signed on 09/26/2024 01:40 PM - It Cannot Be Edited


Created By: Sara Martinez On 09/26/2024 at 12:40 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: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in having an Infection Control Plan available for review during LPA's inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee will ensure an Infection Control Plan will be created for the facility and will submit proof of Infection Control Plan to LPA by the plan of correction date 10/18/2024
Type B
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 interviews and record review, the licensee did not comply with the section cited above in having a currently certified Administrator with an active Administrator Certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee will ensure the facility will have an active Administrator with a certified Administrator Certificate working and associated to the facility by the plan of correction date 10/18/2024
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:Tricia Danielson
LICENSING EVALUATOR NAME:Sara Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/26/2024 01:40 PM - It Cannot Be Edited


Created By: Sara Martinez On 09/26/2024 at 12:40 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: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in one out of two client files not being completed with current records not maintained in the facility during LPA's visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee will ensure C2's file will be completed and have required client records updated if necessary and will send client records (Admissions Agreement, IPP, Physician's Report) to LPA as proof of correction by the plan of correction date 10/18/2024.
Type B
Section Cited
CCR
80069(b)(1)
(b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. (1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in two out of two clients not having a current Physician's Report available for review during the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee will ensure the medical assessment and Physician's Report for C1 and C2 will be conducted and completed and sent to LPA as proof of correction by the plan of correction date 10/18/2024
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:Tricia Danielson
LICENSING EVALUATOR NAME:Sara Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3