361800217-9-8-2023-56-AS-MMAE-CVGU8B-20230908152116

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361800217
Report Date: 09/08/2023
Date Signed: 09/08/2023 03:21:22 PM

Document Has Been Signed on 09/08/2023 03:21 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	FERN HOME III LLC		FACILITY NUMBER:	361800217
ADMINISTRATOR:	GUBALANE, JOI MAE		FACILITY TYPE:	740
ADDRESS:	1841 SHEDDEN DRIVE		TELEPHONE:	(909) 894-3131
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY:	6	CENSUS: 6	DATE:	09/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Joi Mae Guabalane, Administrator		TIME COMPLETED:	03:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Joi Mae Guabalane,Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) with a current census of (6). Facility is operating within capacity. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: LPA inspected the facility inside and out. Indoor and outdoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Facility has no outdoor bodies of water. Facility backyard is enclosed by a fence with self-closing gates and covered patio is sufficient for outdoor client use. LPA inspected the kitchen. The refrigerator and freezer are operating in a healthful manner. Hot water temperature is maintained at 105 degrees F. Facility has sufficient non-perishable and perishable food supply for clients in care. Facility has sufficient cups, plates, and utensils for client use. LPA inspected client bedrooms. Bedrooms are equipped with beds, bed linen, nightstands, chairs, and sufficient lighting. LPA inspected client bathrooms. Bathroom equipment is operating in safe and sanitary conditions. Bathroom hot water temperatures tested between 105 and 110 degrees F.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FERN HOME III LLC	FACILITY NUMBER: 361800217
	VISIT DATE: 09/08/2023

NARRATIVE

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LPA observed the facility is equipped with operating carbon monoxide alarms and operating telephone service. Posters such as Ombudsman contact, emergency phone numbers, evacuation plan, and personal rights are posted in a common area. Facility has a complete first aid kit. Facility has sufficient linen, emergency supplies, and personal hygiene products for clients. Sharps, disinfectants, cleaning solutions, and toxins are kept in a locked cabinet.
Client medications are kept in a safe and locked cabinet, inaccessible to clients in care. All medications are labeled and administered as prescribed.
LPA reviewed staff files for first aid certifications, fingerprint clearances/exemptions, health screenings, training, and personnel records. Staff 1 (S1) health screening is incomplete. Deficiency cite.
All client records reviewed had admissions agreements, physician's reports, assessments, personal rights, and safeguarded resource records.
An exit interview was conducted, where the licensing reports were discussed and a copy of the reports with appeal rights was provided to the Administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/08/2023 03:21 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FERN HOME III LLC	FACILITY NUMBER: 361800217
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review, the licensee did not comply with the section cited above by Staff #1 (S1) health screening is incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2023
	Plan of Correction
1 2 3 4	Administrator shall provide proof of health test result for Staff #1 to the licensing agency by POC date.

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC809 (FAS) - (06/04)

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