331800142-2-8-2023-18-AS-DMUN-CNWSYE-20230210131727

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800142
Report Date: 02/08/2023
Date Signed: 02/08/2023 09:47:17 AM

Substantiated

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
10/12/2021 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211012113454

FACILITY NAME:	FERN HOME I		FACILITY NUMBER:	331800142
ADMINISTRATOR:	GUBALANE, JOI MAE		FACILITY TYPE:	740
ADDRESS:	3875 MEGGINGSON LANE		TELEPHONE:	(951) 299-7619
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92503
CAPACITY:	6	CENSUS: 5	DATE:	02/08/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Joi Mae Gubalane, Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Lack of care and supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to conclude a complaint investigation into the allegation listed above. LPA met with Administrator (AD) Joi Mae Gubalane and discussed the purpose of the visit. Regarding the allegation "Lack of care and supervision". It was alleged that Resident #1's(R1's) pressure injury developed maggots while in care due to neglect. R1 was admitted to the facility on August 28, 2021 and was discharged from the facility on October 17, 2021. During the initial facility visit on October 12, 2021, LPA observed flies in the facility and records reviewed revealed hospice staff had “occasionally” observed flies in the facility. AD Gubalane reported she has to continually remind staff to keep the rear sliding door shut. Interviews conducted with two (2) of two (2) witnesses revealed the wound on R1’s legs were observed to have live maggots on the outside of the bandages and more maggots “poured out” of R1’s bandages when they were cut. During interviews with facility staff, three (3) of three (3) facility staff denied ever observing maggots on R1's wounds. However, photographic evidence obtained by R1’s hospice agency confirmed the presence of live maggots on R1's leg wounds. Hospice records reviewed revealed facility staff were educated on September 27, 2021 and again on September 29, 2021 regarding the need to reposition R1 every two (2) hours to prevent further damage to R1’s pressure injuries.(CONTINUED ON LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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-20211012113454

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/22/2023 Section Cited CCR 87468.2	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1... residents in privately operated residential care facilities for the elderly shall have... the following personal rights:(8)To be free from neglect...or sexual abuse. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The facility states training will be conducted with all staff regarding the importance of following directions given by hospice staff. Proof of training to be provided to CCL by POC due date of 2/22/2023.
	8 9 10 11 12 13 14	The licensee did not ensure R1 was free from neglect. Based on interviews and record review, facility staff neglected the wounds of R1 which resulted in the development of maggots on R1's leg wounds. This poses an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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
10/12/2021 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211012113454

FACILITY NAME:	FERN HOME I		FACILITY NUMBER:	331800142
ADMINISTRATOR:	GUBALANE, JOI MAE		FACILITY TYPE:	740
ADDRESS:	3875 MEGGINGSON LANE		TELEPHONE:	(951) 299-7619
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92503
CAPACITY:	6	CENSUS: 5	DATE:	02/08/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Joi Mae Gubalane, Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Facility is not kept at a comfortable temperature

INVESTIGATION FINDINGS:

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Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegation listed above. LPA met with Administrator Joi Mae Gubalane and discussed the purpose of the visit. Regarding the allegation "Facility is not kept at a comfortable temperature", it was alleged that Resident #1(R1's) room was "hot". During facility visit on October 12, 2021, LPA measured the room temperature of R1's room to be 75.8 degrees Fahrenheit. Interviews were conducted with four(4) of five(5) residents in care. Two(2) of two (2) residents interviewed who were reliable historians, reported the facility has was maintained at a comfortable temperature. Two (2) other residents interviewed were not reliable historians. LPA measured facility temperature in R1's room to be 73.6 degrees Fahrenheit. Temperatures were also measured throught the facility including the rooms of the other residents. Temperatures measured at 74.0, 74.9, 75.1, 73.9, and 74.3 degrees Fahrenheit. The temperature of the living room area was measured at 74.6 degrees Fahrenheit. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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-20211012113454

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: 02/08/2023

NARRATIVE

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(CONTINUED FROM LIC9099)
Staff were also educated on the use of a foam wedge to assist R1’s positioning. Staff acknowledged understanding of this on both dates. Interview with R1’s hospice agency staff indicated there was “nothing to indicate that they didn’t understand” however, R1 was “always” lying on their back. Interviews with R1 revealed the resident was not repositioned every two hours. Interviews conducted with facility staff revealed staff turned R1 only once in the morning and once in the afternoon.
Based on Community Care Licensing staff observations, interviews which were conducted, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099 D. An exit interview was conducted with AD Gubalane, and a copy of this report was provided along with Appeal Rights.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC9099 (FAS) - (06/04)

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