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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423314
Report Date: 10/02/2024
Date Signed: 10/02/2024 12:48:37 PM

Document Has Been Signed on 10/02/2024 12:48 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:FAMOUS HOMEFACILITY NUMBER:
336423314
ADMINISTRATOR/
DIRECTOR:		FEDELIA B. DAIZFACILITY TYPE:
740
ADDRESS:26690 MCCLURE COURTTELEPHONE:
(951) 943-6049
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY: 6CENSUS: 6DATE:
10/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Fedelia Daiz- LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Debbie Palacios and Sara Martinez made an unannounced visit to the facility to conduct a 1 year required inspection. LPAs were greeted and Licensee Fedelia Daiz provided the facility tour.

LPAs conducted a tour of the interior and The facility is a single story home consisting of 4 bedrooms, 2 bathrooms, kitchen, living room, and 1 staff room. The facility was observed to be clean, clutter, and free from obstructions in the passageways. LPAs observed a hand rail in a hallway leading to a Resident's room to be hanging off from the wall which is a potential health and safety risk for residents in care. A deficiency will be issued under Title 22 Regulation 87303(a) along with a plan of corrections. The facility was observed to have personal protective equipment (PPE) supplies. There are no known guns or ammunition on the premises. The smoke detector and carbon monoxide was operational, and the hot water temperature met department requirements. The facility has a record of emergency disaster drills being conducted but last emergency drill conducted was on 05/16/2024 which it does not meet Department requirements.Deficiency cited under Health and Safety Code 1569.695(c) along with the plan of corrections.

Detergents, cleaning solutions, and sharp and dangerous objects were observed to be unlocked and were accessible to residents which is a potential health and safety risk for residents in care. A deficiency will be issued under Title 22 Regulation 87309(a). LPAs observed that the facility had expired food in the refrigerator and in pantry; a deficiency will be issued under Title 22 regulation 87555(b)(8).

LPAs reviewed staff files and training. All staff have the required personnel records on file and criminal record clearance. LPAs observed that staff (1) did not have the required Annual training. A deficiency will issued under Health and Safety regulation 1569.625(b)(2).Three (3) resident files were reviewed and possessed all required paperwork which included Admissions Agreement, Needs and Service Plan, and updated Physician's Report.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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 6
Document Has Been Signed on 10/02/2024 12:48 PM - It Cannot Be Edited


Created By: Debbie Palacios On 10/02/2024 at 11:00 AM
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: FAMOUS HOME
FACILITY NUMBER: 336423314

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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 on keeping cleaning solutions and sharp object inaccessible to the residents in care 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 provide staff training for this regulation cited to ensure that items that can pose a danger are locked and inaccessible to residents. Licensee will submit proof of training to LPA by the Plan of Correction date 10/18/2024.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 staff conducting the 20 hours annual training requirements 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 provide proof of training and training materials for all staff working at this facility to LPA 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:Debbie Palacios
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 10/02/2024 12:48 PM - It Cannot Be Edited


Created By: Debbie Palacios On 10/02/2024 at 11:00 AM
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: FAMOUS HOME
FACILITY NUMBER: 336423314

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in having multiple amounts of expired food in the refrigerator and pantry 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 conduct staff training regarding inspection for the quality of food that is stored at the facility. Licensee will purchase food of good quality for the residents in care and will provide proof of receipt and proof of staff training to LPA by the Plan of Correction date by 10/18/2024.
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above for resident one (R1) receiving PRN medication without staff documenting dates and time. 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 conduct training with staff regarding administering PRNs to residents in care and documenting when given. Licensee will submit proof of training materials and staff signatures of who attended the training to LPA 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:Debbie Palacios
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/02/2024 12:48 PM - It Cannot Be Edited


Created By: Debbie Palacios On 10/02/2024 at 11:00 AM
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: FAMOUS HOME
FACILITY NUMBER: 336423314

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 on not conduct the quarterly drill. Last drill conducted was on 05/16/2024 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 agrees to conduct the fire drill on a quarterly basis and will submit the fire drill conducted by the Plan of Correction date 10/18/2024.
Type B
Section Cited
CCR
87303(a)
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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having a hand rail hanging off the wall by the resident's room located in the hallway 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 agrees to fix the hand rail so it is not hanging off the wall and will send proof of correction and repair 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:Debbie Palacios
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: FAMOUS HOME
FACILITY NUMBER: 336423314
VISIT DATE: 10/02/2024
NARRATIVE
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The listed administrator possesses a current administrator's certificate that expires in 2025. Resident medication was centrally stored and locked in a medication cabinet located in the kitchen. LPAs reviewed medications prescribed to three (3) residents and found all medication with required labeling found to be in place. LPAs observed Resident one (R1) had PRN administered without required documentation of day and time given. A Deficiency will be issued under Title 22 regulation 87465(d)(3). LPAs reviewed the facility's emergency and disaster plan.
Based on today's visit citations were issued on the attached 809D, in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted and a copy of this report, appeal rights, LIC 811 were provided to Fedelia Daiz, Licensee.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC809 (FAS) - (06/04)
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