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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800142
Report Date: 07/10/2023
Date Signed: 07/10/2023 11:36:31 AM


Document Has Been Signed on 07/10/2023 11:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:FERN HOME IFACILITY NUMBER:
331800142
ADMINISTRATOR:GUBALANE, JOI MAEFACILITY TYPE:
740
ADDRESS:3875 MEGGINGSON LANETELEPHONE:
(951) 299-7619
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 5DATE:
07/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Joi Mae GubalaneTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPA met with Administrator Joi Mae Gubalane and explained the purpose of today's visit.

Five(5) of five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well.
Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit.

An exit interview was conducted and a copy of this report was provided to administrator Joi Mae Gubalane.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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