331800142-10-12-2021-18-AS-DMUN-CNWSYF-20230210131728

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800142
Report Date: 10/12/2021
Date Signed: 10/12/2021 01:45:26 PM

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:	10/12/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Joi Mae Gubalane, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility staff did not keep the facility free of flies
Facility is not kept clean

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to initiate a complaint investigation into the allegations list above. LPA was greeted upon entry by caregiver Joselyn Tolentino. Tolentino phoned Administrator (AD) Joi Mae Gubalane of LPA's presence in the facility and she arrived moments later. LPA discussed the purpose of the visit with AD.
During today's visit, LPA toured the facility, interviewed four (4) of five (5) residents, one (1) staff, and reviewed pertinent documents and records. LPA also obtained copies of pertinent documents and records. Regarding the allegation "facility did not keep the facility free of flies", one (1) of two (2) residents interviewed who were reliable historians, reported the facility has an issue with flies. Two (2) other residents interviewed were not reliable historians. The fifth (5th) resident of the facility was not home at the time of LPA's visit and was therefore not interviewed. LPA personally observed flies in the front TV room of the facility as well as a fly swatter being stored on top of the wall furnance in the same room. Interview with AD revealed the facility does have flies in the facility on occasion. Regarding the allegation "facility is not kept clean", it was alleged that the room of resident #1 (R1) was not kept in a clean manner. LPA observed (CONTINUED ON LIC9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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
	VISIT DATE: 10/12/2021

NARRATIVE

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(CONTINUED FROM LIC9099)
numerous stacks of adult briefs being kept in a corner of R1's room. LPA also observed a box of goldfish crackers on a bedside table in R1's room and tins of cookies being kept on top of the stacked adult briefs. In the kitchen, LPA observed a grease splattered wall behind the stove and the microwave above the stove was also grease splattered. LPA also observed the stove top itself to be unclean.
Based on LPA's observations, interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code Of Regulations, Title 22, Division 6, Chapter 8 are 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: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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: 10/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/22/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation- (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee states facility staff will ensure the rear facility door is not left open to allow flies into the facility and conduct a training. Licensee stated the facility will store the adult briefs in a storage closet. Licensee stated facility staff will clean the kitchen stove, microwave and walls and maintain it in a clean manner by POC due date.
	8 9 10 11 12 13 14	Based on LPA's observations, the licensee did not ensure the faciltiy was maintained in a clean manner. LPA observed the stove top, microwave, and kitchen wall behind the stove to be splattered with grease. LPA also observed flies in the facility and a fly swatter being stored in a very easily accessable (cont in right column)	8 9 10 11 12 13 14	manner. 1 of 2 residents interviewed reported the facility has flies. Interview with AD also revealed the facility has an issue with flies. LPA also observed multiple stacks of adult briefs being stored in room #2. This poses a potential health, safety, and personal rights risk to residents in care.
CCR	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: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC9099 (FAS) - (06/04)

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