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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800143
Report Date: 02/18/2022
Date Signed: 02/18/2022 01:34:22 PM


Document Has Been Signed on 02/18/2022 01:34 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:FERN HOME IIFACILITY NUMBER:
331800143
ADMINISTRATOR:CABUSAO, ELBERTOFACILITY TYPE:
740
ADDRESS:3877 MEGGINSON LANETELEPHONE:
(951) 299-7087
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 4DATE:
02/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Joi Ma Gubalane, AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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Regional Manager (RM) Reyna Lacey, Licensing Program Manager (LPM) Deborah Mullen, and Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to check for any immediate health and safety needs. Licensing staff met with Administrator Joi Ma Gubalane.

Licensing staff toured the facility with Ms. Gubalane. Currently there are 2 caregivers to provide for the needs of the residents in care. Licensing staff reviewed and obtained copies of resident files.

Ms. Gubalane will submit a packet to change administrator of record to herself. The packet will be submitted by the close of business on 02/22/2022. Ms. Gubalane will submit an updated Designation of Facility Responsibility (LIC308) by close of business on 02/22/2022.

At approximately 08:50am, It was found that the facility did not have a fire clearance for bedridden residents. Licensee did not obtain a fire clearance for Resident Two (R2). Staff interviews revealed R2 needs assistance in turning and repositioning. A Type A citation was issued per Title 22 Division 6 Chapter 8 Article 12 and an Immediate civil penalty was issued in the amount of $500 for the absence of fire clearance for bedridden residents.

At approximately 08:50am, a review of R2's file was conducted and revealed written instructions to caregivers that R2 is to be repositioned every 2 hours. Licensing staff observed S1, at approximately 12:55pm, request R2 to reposition on their own, and R2 indicated that they couldn't.

An exit interview was conducted with Ms. Gubalane, and copies of this report along with LIC811, LIC809-D, and LIC421IM, and Appeal Rights were provided to Ms. Gubalane.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
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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Document Has Been Signed on 02/18/2022 01:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2022
Section Cited

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CARE OF BEDRIDDEN RESIDENTS. (c) To accept or retain a bedridden person. Licensee did not meet the regulation as evidenced by:
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Based on LPAs observation, and interview, Licensee did not obtain a bedridden fire clearance to retain R2. R2 is bedridden.This presents an immediate health and safety risk to residents in care.
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Copy of eviction notice shall be submitted by 2/22/2022. LPA informed Administrator to review CCR 87224 Eviction Procedures.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
LIC809 (FAS) - (06/04)
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