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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336423314
Report Date: 08/19/2025
Date Signed: 08/19/2025 12:10:14 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
05/23/2025 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20250523161729
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:
08/19/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee, Fidelia DiazTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility has insufficient staffing to meet the needs of the residents
Licensee does not have an appropriate emergency disaster plan
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with Licensee, Fidelia Diaz, who was informed of the purpose of the visit. During the visit, LPA conducted interviews and records review.
It was alleged “Facility has insufficient staffing to meet the needs of the residents”. It was alleged that there is only (1) staff present at a time, and that there is no awake staff to assist residents at night from 8pm to 6am. LPA reviewed the Preplacement Appraisal for all (6) residents which revealed (2) residents require night supervision. LPA reviewed the care plans for all resident which revealed (2) residents need incontinence care and repositioning.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
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 5
Control Number 18-AS-20250523161729
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/19/2025
NARRATIVE
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LPA conducted (2) staff interviews which revealed there is (1) staff on call at night from 8pm to 6am and wait times for assistance are around (5) minutes. All staff interviewed revealed night staff is asleep at night, and all residents are able to verbalize their needs and call when assistance is needed in between checks. All staff interviewed revealed (2) residents require checks at night for incontinence care and turning every (2) hours.

LPA conducted (6) resident interviews. All residents interviewed revealed there is (1) staff member at the facility on call at night from 8pm to 6am and residents need to call for assistance. (4) of (6) residents revealed staff come and check on residents and change and turn R1 and R2 at night with reported wait times of (3) to (10) minutes. (1) of (6) residents, stated staff responds fifty percent of the time at night, and reported waiting (30) minutes for assistance. (1) of (6) residents revealed they do not call for help at night.

Therefore, based on pre-placement appraisal of night supervision needed for (2) residents, and the staff and resident statements that the only staff present is asleep and on call at night the allegation that the facility is insufficiently staffed to meet the needs of the residents is substantiated.

It was alleged “Licensee does not have an appropriate emergency disaster plan”. It was alleged that there is not enough staff to assist residents in case of an emergency.

LPA reviewed the Emergency and Disaster Plan LIC610E, listing the emergency agencies that will be contacted to assist with evacuation, and that staff from all shifts will be called to assist in evacuating and transporting residents. LPA conducted (2) staff interviews and (6) resident interviews revealing there is (1) staff present who is allowed to sleep from 8pm to 6am. All staff interviewed stated there is enough staff available to evacuate residents to safety with (1) staff on the premises and (3) staff on call in the vicinity to assist.

LPA reviewed all resident LIC602 Physician's Reports revealing their ambulatory status and ability to transfer. (5) of (6) residents are non-ambulatory while (1) of (6) residents is bedridden.

SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20250523161729
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/19/2025
NARRATIVE
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(6) resident interviews and (2) staff interviews revealed the bedridden resident requires total assistance when evacuating, (2) non ambulatory residents require assistance to get into and be pushed in their wheelchairs, while (3) non ambulatory residents have assistive devices they can access on their own and can evacuate on their own in case of an emergency.

Therefore, based on resident ambulatory statuses and resident and staff interviews the allegation that the facility does not have an appropriate emergency and disaster plan is substantiated. Based on (1) staff being on call on the premises and (3) residents requiring assistance to evacuate in case of an emergency.

The preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations Title 22 is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report and appeal rights were reviewed and provided.

SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20250523161729
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities


(a)In addition to the rights listed in Section 87468.1…elderly shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers…to meet their needs. This requirement was not met as evidenced by:
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The licensee agreed to submit an LIC500 showing staffing at night and for emergency assistance. The licensee agreed to update their LIC610E plan to reflecting staffing and evacuation level.
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Based on interviews and records review, the facility is not staffed sufficiently at night from 8pm to 6am to meet night supervision needs documented for residents. Based on resident ambulatory status and ability to evacuate in an emergency, the facility is also not sufficiently staffed to evacuate (3) residents who require total assistance with (1) on call staff on the premises. This poses a potential health safety or personal rights risk to residents in care.
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The licensee also agreed to submit a written procedure for staff on how residents needs for turing and repositioning will be met at night.
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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: Carolyn Tuba
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
05/23/2025 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20250523161729

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:
08/19/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee, Fidelia DiazTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff are unable to communicate with residents due to a language barrier
INVESTIGATION FINDINGS:
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It was alleged “Staff are unable to communicate with residents due to a language barrier.” It was alleged that Staff #1 (S1) speaks minimal English and cannot communicate with the residents to meet their needs. LPA conducted (6) resident interviews which revealed that all (6) residents are able to communicate their care needs to S1, and S1 is able to understand their care needs. LPA conducted interview with (1) staff and S1 which revealed S1 is able to communicate with residents and understand their care needs without an issue. LPA conducted a visits on 05/29/2025 and 08/13/2025, where LPA observed residents calling on S1 and communicating with S1 in English. LPA observed S1 responding to residents needs and assisting with activities of daily living. LPA was able to conduct the visit and communicate with S1 and interview S1 with no issues. Therefore, the allegation that staff cannot communicate with residents to meet their needs is unfounded at this time, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5