<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800142
Report Date: 03/07/2025
Date Signed: 03/07/2025 05:21:57 PM

Document Has Been Signed on 03/07/2025 05:21 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:FERN HOME IFACILITY NUMBER:
331800142
ADMINISTRATOR/
DIRECTOR:		GUBALANE, JOI MAEFACILITY TYPE:
740
ADDRESS:3875 MEGGINGSON LANETELEPHONE:
(951) 299-7619
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 6CENSUS: 4DATE:
03/07/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:50 PM
MET WITH:Joi Mae Gubalane, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:40 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 Analysts (LPAs) Seo Jeon 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. LPA met with Administrator, Joi Mae Gubalane, who was informed of the purpose of the visit.

LPA toured the facility and observed all facility utilities to be on and operating without issues. The food supply meets the 7-day non-perishables, and 2-day perishables regulatory requirement. There are no immediate concerns for residents in care.

No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6.

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

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1