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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800142
Report Date: 04/10/2024
Date Signed: 04/10/2024 02:03:22 PM


Document Has Been Signed on 04/10/2024 02:03 PM - 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: 5DATE:
04/10/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Licensee - Joi Mae Gubalane TIME COMPLETED:
01:55 PM
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Licensing Program Analysts (LPAs) Sara Martinez and Yolanda Delgado 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. LPAs met with Licensee, Joi Mae Gubalane who was informed of the purpose of the visit.

During today's visit, LPAs conducted a tour of the facility's interior and exterior with Gubalane. LPA observed four (4) residents in care. LPAs were informed one resident is at the hospital. There were no imminent health or safety concerns observed at the time of visit. LPAs observed the facility had working utilities and was operating as usual. LPAs observed adequate staffing to provide care for the residents. LPAs observed the facility had more than a two (2) day supply of perishable foods and seven (7) day supply of non-perishable food items.

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 where a copy of this report was reviewed and provided to Gubalane.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
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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