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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800143
Report Date: 01/18/2024
Date Signed: 01/18/2024 01:24:10 PM


Document Has Been Signed on 01/18/2024 01:24 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 IIFACILITY NUMBER:
331800143
ADMINISTRATOR:JOE MAE GUBALANEFACILITY TYPE:
740
ADDRESS:3877 MEGGINSON LANETELEPHONE:
(951) 299-7087
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 5DATE:
01/18/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Joi Mae Gubalane, LicenseeTIME COMPLETED:
01:00 PM
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On 01/18/2024, Licensing Program Analysts (LPAs) Chinwe Nwogene and Crystal Colvin 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 five (5) residents in care. 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. 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.

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

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
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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