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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800142
Report Date: 11/03/2025
Date Signed: 11/03/2025 03:19:19 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
10/25/2025 and conducted by Evaluator Yolanda Delgado
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20251025000619
FACILITY NAME:FERN HOME IFACILITY NUMBER:
331800142
ADMINISTRATOR:GUBALANE, JOI MAEFACILITY TYPE:
740
ADDRESS:3875 MEGGINGSON LANETELEPHONE:
(951) 299-7619
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 4DATE:
11/03/2025
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Delores Brazil, CaregiverTIME COMPLETED:
03:22 PM
ALLEGATION(S):
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Staff did not keep facility free of hazards.
Staff are not preparing meals for residents in care.
Facility is unkempt.
INVESTIGATION FINDINGS:
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Licensing Program Analyst, (LPA) Yolanda Delgado arrived unannounced to the facility to commence an investigation pertaining to the allegations listed above. LPA met with Delores Brazil and explained the purpose of the visit.

On October 25, 2025, Community Care Licensing received a complaint alleging staff did not keep the facility free of hazards, staff are not preparing meals for residents in care and facility is unkempt. LPA conducted an interview with Administrator which revealed that they had been having issues with electricity with certain electrical outlets and has called out three (3) different electricians to address the problem and the issue has been fixed as of 11/3/2025 by the city of Riverside. Administrator stated that due to the power issues in the kitchen, the stove was unable to be used however, refrigerator, microwave and rice cooker were able to be used, and meals were prepared by caregivers at the facility next door and were brought over to the residents.

(Continued on Page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2025
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 2
Control Number 18-AS-20251025000619
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 I
FACILITY NUMBER: 331800142
VISIT DATE: 11/03/2025
NARRATIVE
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(Continued from Page 1)


Administrator stated there has not been any renovations, however, they are doing minor repairs in the facility. LPA interviewed residents and stated they are given meals by the staff daily and their rooms are cleaned daily by staff; residents are unaware of any hazards in their rooms. LPA did not observe any hazards inside the facility. LPA observed working appliances and working utilities. There are no health and safety concerns with residents in care currently.

Based on interviews and documentation staff did not keep facility free of hazards, staff are not preparing meals for residents in care and facility is unkempt, the allegations are unsubstantiated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted with Joi Mae Gubalane and a copy of this report was provided.

*LPA was away from the facility from 12:20-1:20 pm
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2