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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336423314
Report Date: 10/18/2024
Date Signed: 10/18/2024 04:56:59 PM

Unsubstantiated


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
05/23/2024 and conducted by Evaluator Venus Mixson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240523103450
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: 6DATE:
10/18/2024
UNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:ADMINISTRATOR, FEDELIA B. DAIZTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not allow resident to refuse medication.
Staff locked residents in care for an extended period of time.
Staff do not provide adequate meals to residents in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On October 18, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced and met with Administrator, Fedelia B. Daiz. The visit was conducted to deliver findings for the listed allegations.
During the investigation, LPA interviewed staff, residents, and witness, conducted record reviews, and made observations regarding the list allegations. LPA was unable to interview Resident 1 (R1) due to R1 relocating to another facility.

On May 23, 2024, Community Care Licensing received a complaint alleging staff do not allow resident to refuse medication, staff locked residents in care for an extended period, and staff do not provide adequate meals to residents in care. Further information reported that residents are given medication they are not familiar with. It was also reported that the facility did not have adequate utilities such as inoperable ceiling lights and fans, inoperable electrical outlets, inoperable boiler, and oven in kitchen areas.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
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 4
Control Number 18-AS-20240523103450
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: 10/18/2024
NARRATIVE
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Regarding the allegation staff do not allow resident to refuse medication, three of five staff were interviewed. Three of five staff interviewed revealed R1 would put up a fuss and refuse to take prescribed medication and although R1 would initially refuse, staff would encourage R1 to take their medication and R1 would then oblige without force. Additional interviews with residents indicated they have not missed their medications. The residents did not observe the staff force any of the residents or not allow any of the residents to refuse their medications. Residents indicated they were not forced or did not refuse their medications.

Regarding the allegation staff locked residents in care for an extended period. Interview with Staff Number 2 (S2) indicated there was never a time when any staff left any residents, requiring assistance, unattended or locked them up. Additional interviews with staff corroborated the statements. Information received from interviews with residents corroborated the statements that at no time where residents locked in or unattended to.

Regarding the allegation staff do not provide adequate meals to residents in care, information obtained from resident interviews three of five residents three of the three interviewed, 3 of 5 advised the facility provided home cooked meals. Interviews with residents also indicated there were no concerns regarding the type or amount of food provided by the facility.

Interviews with staff indicated there has not been a time any of the residents have requested more food and were denied food. A review of the records including menus and grocery shopping receipts demonstrated grocery shopping is completed on a weekly basis and the items on the menu match the food available at the facility.

Information obtained from interviews with the administrator stated residents can select the types of food to add to the menu. Additionally, information obtained from resident interviews stated residents have food items of their choice.

Based on information obtained from interviews, record reviews, observation, and the inability to obtain information from pertinent parties there is not a preponderance of evidence to prove the alleged violations occurred. Therefore, the allegations are deemed as unsubstantiated. An exit interview was conducted, and a copy of this report was provided and given to Administrator, Fedelia B. Daiz.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
05/23/2024 and conducted by Evaluator Venus Mixson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240523103450

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: 6DATE:
10/18/2024
UNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:ADMINISTRATOR, FEDELIA B. DAIZTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is in disrepair
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On October 18, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced and met with Administrator, Fedelia B. Daiz. The visit was conducted to deliver findings for the listed allegations.

During the investigation, LPA interviewed staff, residents, and witness, conducted record reviews, and made observations regarding the list allegations. LPA was unable to interview Resident 1 (R1) due to relocating to another facility.

On May 23, 2024, Community Care Licensing received a complaint alleging facility is in disrepair. It was reported the facility did not have adequate utilities as shown to the ombudsman (inoperable ceiling lights and fans, inoperable electrical outlets, inoperable boiler, and oven in kitchen areas.”)

Information obtained from staff interviews advised the utilities were always operable and were never disconnected due to the failure to pay the bill. Review of the records corroborated this. It was further reported all ceiling fans, electrical outlets, kitchen appliances worked. Information obtained from interviews with residents indicated there were no concerns regarding the facility. Information obtained from interview with

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20240523103450
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: 10/18/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Administrator stated they were not aware or advised of any outlets, fans, or appliances not working. Information obtained from a third-party witness indicated during their visits, they did not observe any issues with the electricity or appliances.

On May 24, 2024, and September 19. 2024, LPAs conducted a facility inspection and observed the kitchen appliances, ceiling fans, and outlets to be operable.

Based on information obtained from interviews, record reviews, and observations, the information obtained was not sufficient to demonstrate the listed allegations were valid. Therefore, the allegation has been deemed as unfounded. An allegation deemed unfounded means the allegation is false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was discussed and given to Administrator, Fedelia B. Daiz.


SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4