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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336401433
Report Date: 02/10/2022
Date Signed: 02/10/2022 01:41:28 PM

Document Has Been Signed on 02/10/2022 01:41 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:REAL SWEET HOMEFACILITY NUMBER:
336401433
ADMINISTRATOR:DIAZ, FEDELIAFACILITY TYPE:
740
ADDRESS:20905 EL NIDOTELEPHONE:
(951) 943-8762
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY: 6CENSUS: 5DATE:
02/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:09 PM
MET WITH:Licensee, Fedelia DaizTIME COMPLETED:
01:45 PM
NARRATIVE
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On 2/10/22 LPA Cuevas visited facility to do an annual inspection, while doing walk through of facility with Licensee, Fedelia Daiz LPA identified passageway into kitchen to be obstructed by a door placed sideways. Per Licensee, this is intended to keep pet dog from running out of kitchen.

Based on observation deficiency will be cited on LIC 809 D.

An exit interview was done with Licensee, Fedelia Daiz in which this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2022
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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Document Has Been Signed on 02/10/2022 01:41 PM - It Cannot Be Edited


Created By: David Cuevas On 02/10/2022 at 01:00 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: REAL SWEET HOME
FACILITY NUMBER: 336401433

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2022
Section Cited
CCR
87203

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All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement was not met evidence by.
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Licensee will remove the door placed sideways from passageway by the end of the day 2/10/22 and provided a statement of understanding as it relates to regulation being cited.
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While touring facility LPA identified an obstructed passageway leading into the kitchen, per facility staff this is done to prevent pet dog from going to other areas of the home. This possess an immediate risk to the health and safety of residents in care.
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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:David Cuevas
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2022


LIC809 (FAS) - (06/04)
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