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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423314
Report Date: 03/26/2024
Date Signed: 03/26/2024 01:26:04 PM


Document Has Been Signed on 03/26/2024 01:26 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: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:
03/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Fedelia Daiz, LicenseeTIME COMPLETED:
01:24 PM
NARRATIVE
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Licensing Program Analyst (LPA ) Yolanda Delgado conducted a case management visit during a visit and observed two (2) staff and four (4) residents in care. LPA toured the facility and observed bathroom #1 sink water pressure was low and the shower attachment is not working properly. Food supply was observed and there is sufficient food supply.

One deficiency were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted with Fedelia Daiz and a copy of this report, 809-D and Appeal Rights was provided.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
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 2


Document Has Been Signed on 03/26/2024 01:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/09/2024
Section Cited
CCR
87303(e)(6)

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MAINTENANCE AND OPERATIONS:
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6)...bathing facilities shall be maintained in operating condition...based on the residents' needs.
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Licensee will repair and send copy of invoice to LPA by POC Due date.
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This requirement is not being met as evidenced by: LPA observed the sink pressure very low and shower attachment water pressure is extremly low and a knob is used to turn on and off at the top, bath knobs are not working. This poses a potential health and safety risk to the clients 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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2