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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800142
Report Date: 03/24/2026
Date Signed: 03/24/2026 02:16:42 PM

Substantiated


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
02/16/2022 and conducted by Evaluator Seo Jeon
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220216102150
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:
03/24/2026
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Joi Mae Gubalane, AdministratorTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Conduct Inimical
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegation. LPA met with Joi Mae Gubalane, Administrator. The Department investigation involved interviews with staff and review of records.

On 02/16/2022, Community Care Licensing (The Department) received a complaint report with the following allegation.

The allegation was conduct inimical. Information received indicated that the California Department of Justice conducted an investigation regarding insurance fraud involving one of the facility’s corporate board members (S1). LPA conducted an interview with the Administrator, who stated that the San Bernardino County Superior Court dismissed the case against S1. Continued on LIC9099-C....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
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 3
Control Number 18-AS-20220216102150
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: 03/24/2026
NARRATIVE
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LPA obtained a court document from the Administrator. The court document indicated that a felony charge was dismissed; however, S1 was convicted of a misdemeanor of PC549 and placed on probation. Therefore, the allegation of conduct inimical is substantiated.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted, and a copy of this report was provided along with LIC9099-D and Appeal Rights.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20220216102150
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2026
Section Cited
HSC
1569.58(a)(2)
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1569.58 Persons prohibited from being a licensee...or holding certain positions or employment...(a) The department may prohibit any person from being a licensee... (2)Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services...
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Licensee stated that Staff #1 (S1) is no longer engaged in daily operation of the facility.
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Based on records review, Licensee did not ensure that staff were not engaged in conduct that is inimical to heath and safety of residents in care. This posed an immediate health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3