331800142-8-30-2024-18-AS-KCLS-D8MVGP-20240830162549

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800142
Report Date: 08/30/2024
Date Signed: 08/30/2024 01:49:05 PM

Unsubstantiated

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
11/24/2020 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20201124115756

FACILITY NAME:	FERN HOME I		FACILITY NUMBER:	331800142
ADMINISTRATOR:	GUBALANE, JOI MAE		FACILITY TYPE:	740
ADDRESS:	3875 MEGGINGSON LANE		TELEPHONE:	(310) 997-8204
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92503
CAPACITY:	6	CENSUS: 3	DATE:	08/30/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Joi Gubalane, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff do not administer medications to residents.

Facility staff leave residents unattended while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Javier Prieto and LPA Lavette Farlow arrived to the facility to conclude a complaint investigation regarding the above allegations. LPAs met with administrator Gubalane and explained the elements of the complaint.

Allegation #1 - Resident #1 in question, no longer resides at the home, but medical records review for resident #2 (R2), (R3) and (R4) will show that medications are being administered as prescribed. Allegation #2 - Administrator Gubalane provided staff roster to show that the facility is adequately staff to meet the needs of the clients in care. Upon arrival, LPA's observed 2 direct staff present as well as the administrator present.

Based on the information obtained there is not enough evidence that facility staff do not administer medications to residents and facility staff leave residents unattended while in care. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto, LPA Farlow and Administrator Gubalane and a copy was left with the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024

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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