331800143-9-30-2020-18-AS-NBRN-BU5R8Y-20201006124840

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800143
Report Date: 09/08/2020
Date Signed: 09/30/2020 04:25:23 PM

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
08/27/2020 and conducted by Evaluator Susan Parker

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200827100100

FACILITY NAME:	FERN HOME II		FACILITY NUMBER:	331800143
ADMINISTRATOR:	CABUSAO, ELBERTO		FACILITY TYPE:	740
ADDRESS:	3877 MEGGINSON LANE		TELEPHONE:	(310) 997-8204
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92503
CAPACITY:	6	CENSUS: 5	DATE:	09/08/2020
		UNANNOUNCED	TIME BEGAN:	04:10 PM
MET WITH:	Joi Gubalane		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Facility has insufficient funds to meet residents' needs
Food service is inadequate

INVESTIGATION FINDINGS:

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Licensing Program Analyst Susan Parker contacted the facility via telephone, due to COVID-19, to deliver the final complaint investigation report regarding the above allegations.

The investigation consisted of the following: LPA Parker conducted internet research to see if the LLC is active; interviewed the administrator, staff #1 and #2, residents #1, #2 and #3; LPA checked to ensure the facility telephone is working; LPA Parker received/reviewed the following documents: facility food budget, proof that staff are getting paid, control of property; LPA Parker toured the facility to make sure the electricity was on, to make sure there was a sufficient amount of food, to make sure there were beds for all residents, comfortable furnishings, and that there were cleaning supplies/PPE supplies.

The investigation revealed the following: LPA Parker interviewed the residents who live in this facility (residents #1, #2 and #3). The residents all indicated they are pleased with the food they are getting, they are free to watch TV when they want and they said the air conditioner keeps the facility at a nice temperature. They said the toilets are working properly, and there are always staff there.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Susan Parker	TELEPHONE: (951) 897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2020

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-20200827100100

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 II	FACILITY NUMBER: 331800143
	VISIT DATE: 09/08/2020

NARRATIVE

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LPA Parker interviewed 2 staff and they said they are getting paid regularly. LPA Parker did a virtual tour of the facility and was able to see lights and TV on. LPA saw a 2 day supply of perishable foods and a 7 day supply of non-perishable foods. A review of the food budget showed the amount of money spent on food each month is sufficient. The administrator said she has not filed for bankruptcy. A review of the control of property indicates the licensee is not in danger of being put out of the facility.

This agency has investigated the complaint alleging "facility has insufficient funds to meet residents' needs", and "food service is inadequate." We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted with Joi Gubalane via telephone, due to COVID-19, and a copy of this report was provided to Mrs. Gubalane.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Susan Parker	TELEPHONE: (951) 897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2020

LIC9099 (FAS) - (06/04)

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