331800142-9-8-2020-18-AS-NBRN-BTWTNP-20200929145303

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800142
Report Date: 09/08/2020
Date Signed: 09/08/2020 04:27:34 PM

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
08/27/2020 and conducted by Evaluator Susan Parker

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200827092052

FACILITY NAME:	FERN HOME I		FACILITY NUMBER:	331800142
ADMINISTRATOR:	GUBALANE, JOI MAE		FACILITY TYPE:	740
ADDRESS:	3875 MEGGINGSON LANE		TELEPHONE:	(310) 997-8204
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92503
CAPACITY:	6	CENSUS: 3	DATE:	09/08/2020
		UNANNOUNCED	TIME BEGAN:	04:10 PM
MET WITH:	Joi Gubalane		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Facility has insufficient funds to meet residents' needs
Food service is inadequate

INVESTIGATION FINDINGS:

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Licensing Program Analyst Susan Parker contacted the facility via telephone, due to COVID-19, to deliver the final complaint investigation report regarding the above allegations.

The investigation consisted of the following: LPA Parker conducted internet research to see if the LLC is active; interviewed the administrator, staff #1, residents #1, #2 and #3; LPA checked to ensure the facility telephone is working; LPA Parker received/reviewed the following documents: facility food budget, proof that staff are getting paid, control of property; LPA Parker toured the facility and observed the electricity is working, required amount of perishable & non-perishable foods; beds for all residents, comfortable furnishings, cleaning supplies/PPE supplies.

The investigation revealed the following: LPA Parker interviewed the residents who live in this facility (residents #1, #2 and #3). The residents all indicate they are getting 3 meals per day, between meal snacks, they watch TV when they want to, the air conditioner is working fine, the toilets are all working, and there are staff working there

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Susan Parker	TELEPHONE: (951) 897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200827092052

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: FERN HOME I	FACILITY NUMBER: 331800142
	VISIT DATE: 09/08/2020

NARRATIVE

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everyday to meet their needs. LPA Parker interviewed the staff and they said they are getting paid regularly. LPA toured the facility via FaceTime, and saw that the electricity is working (lights were on, T.V. was on), LPA saw a 2 day supply of perishable foods and a 7 day supply of non-perishable foods. LPA Parker reviewed the food budget and saw the amount of money the administrator spends on food each month, and it is sufficient for 3 residents. The administrator said she has not filed for bankruptcy. A review of the control of property indicates the licensee is not in danger of being put out of the facility.

This agency has investigated the complaint alleging "facility has insufficient funds to meet residents' needs", and "food service is inadequate." We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted with Joi Gubalane via telephone, due to COVID-19, and a copy of this report was provided to Mrs. Gubalane.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Susan Parker	TELEPHONE: (951) 897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2020

LIC9099 (FAS) - (06/04)

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