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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336423314
Report Date: 06/21/2021
Date Signed: 06/21/2021 01:42:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/14/2021 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210614144302
FACILITY NAME:FAMOUS HOMEFACILITY NUMBER:
336423314
ADMINISTRATOR:FEDELIA B. DAIZFACILITY TYPE:
740
ADDRESS:26690 MCCLURE COURTTELEPHONE:
(951) 943-6049
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY:6CENSUS: 4DATE:
06/21/2021
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Fedelia DaizTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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The facility is unsanitary
Kitchen appliances are in disrepair.
The facility does not maintain a 2 day supply of perishable foods on the premises.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to initiate a complaint investigation into the above allegation. LPA met with Licensee/Administrator, Fedelia Daiz, and discussed the purpose of the visit. The investigation consisted of direct observation and interviews with staff.

In regards to allegation #1, LPA inspected the kitchen and observed that there were dead ants on the kitchen countertops. LPA interviewed Staff #1 (S1) who stated that the ants were sprayed on the counter tops but staff forgot to wipe them off.

In regards to allegation #2, LPA observed that the dishwasher was not functioning properly. LPA also observed that the refrigerator light was not operating.

In regards to allegation #3, LPA inspected the facility's food supply and observed that there was not a two
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
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 3
Control Number 18-AS-20210614144302
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FAMOUS HOME
FACILITY NUMBER: 336423314
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2021
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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Licensee agreed to have a deep cleaning done for the kitchen, including wiping down kitchen countertops, the walls, all appliances, and have the dishwasher replaced by POC date of 6/28/2021. Licensee agreed to send pictures of the kitchen once completed.
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Based on observation, Licensee did not ensure that the kitchen was clean, sanitary, and in good repair. LPA observed insects on the kitchen countertops and the dishwasher and refrigerator in disrepair at the time of visit.
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Type B
06/28/2021
Section Cited
CCR
87555(b)(26)
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87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not as evidenced by:
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Licensee agreed to purchase a two day supply of perishable foods and provide a copy of the receipt to the Department by POC date of 6/28/2021.
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Based on observation, Licensee did not ensure that a two day supply of perishable foods were maintained on the premises at the time of visit.
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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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20210614144302
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: FAMOUS HOME
FACILITY NUMBER: 336423314
VISIT DATE: 06/21/2021
NARRATIVE
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day supply of perishable foods at the time of visit for the four residents in care.

Based on the evidence gathered during today's visit, the above allegation is SUBSTANTIATED. A finding that the allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where this report was discussed and a copy was provided to Daiz.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3