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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800142
Report Date: 11/22/2023
Date Signed: 11/22/2023 11:53:29 AM


Document Has Been Signed on 11/22/2023 11:53 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 ASC, 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: 4DATE:
11/22/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Joi Mae GubalaneTIME COMPLETED:
11:45 AM
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On 11/22/2023, Licensing Program Analyst (LPA) Janette Romero conducted a case management visit relative to complaint 18-AS-20220216102150, to check on the health, safety, and well-being of the residents in care. LPA was granted entry by Administrator Joi Mae Gubalane who was informed of the purpose of the visit.

During today's visit, LPA conducted a tour of the facility's interior and exterior with Administrator Gubalane. LPA observed four (4) residents in care. There were no imminent health or safety concerns observed at the time of visit. LPA observed the facility had working utilities and was operating as usual. LPA observed adequate staffing to provide care for the residents. LPA observed the facility had a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable food items along with an emergency food supply stored in the medication cabinet. 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. LPA issued a Technical Advisory to remove the trash and piles of wood that are next to the brick wall, which may be a potential/fire hazard.

An exit interview was conducted where a copy of this report was reviewed and provided to Administrator Gubalane.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023
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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