331800143-10-12-2021-18-AS-DMUN-C8N3F5-20211110171209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800143
Report Date: 10/12/2021
Date Signed: 10/12/2021 01:22:38 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
10/08/2021 and conducted by Evaluator Tricia Danielson

COMPLAINT CONTROL NUMBER: 18-AS-20211008083811

FACILITY NAME:	FERN HOME II		FACILITY NUMBER:	331800143
ADMINISTRATOR:	CABUSAO, ELBERTO		FACILITY TYPE:	740
ADDRESS:	3877 MEGGINSON LANE		TELEPHONE:	(951) 299-7087
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92503
CAPACITY:	6	CENSUS: 6	DATE:	10/12/2021
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Joi Mae Gubalane, Administrator		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Personal Rights
Facility staff did not keep the facility free of flies
Facility is not kept at a comfortable temperature
Facility is not kept clean

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to intiate a complaint investigation into the allegations listed above. LPA was granted to the facility by caregiver Jocelyn Tolentino and announced the purpose of the visit. Tolentino phoned Administrator (AD) Joi Mae Gubalane to notify her of LPA's presence in the facility. AD Gubalane arrived shortly thereafter.

LPA discussed the allegations with AD Gubabalne and discovered the above allegations concerned the sister facility Fern Home I and do not pertain to the residents or conditions at Fern Home II. Therefore, the above allegations are unfounded.

An exit interview was conducted and a copy of this report was provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3