Fern Home III

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarina Ramirez made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator Joi Mae Gubalane, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6), a current census of (6). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility does not have a swimming pool or similar bodies of water. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has sufficient indoor and outdoor space for resident activities. The facility is equipped with operating smoke detectors/carbon monoxide alarms, working laundry equipment, and telephone service. Resident’s showers, toilets, and hand washing areas were operating properly. The hot water temperature in two (2) resident bathrooms measured between 116.2 and 116.8 degrees F. Four (4) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, facility license, administrator certificate, facility sketch, personal rights, CCLD complaint poster, and Ombudsman poster. Food Service: Facility kitchen and dining area are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps and chemicals were kept locked and inaccessible to residents in care. Continuation on LIC – 809C: Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff have current CPR/first aid training. Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet, however MAR was not checked off beyond July 10,2026; Deficiency issued. Record Review: Two (2) Staff files reviewed were observed to be incomplete, staff #2 did not having a signed health screening; deficiency issued. Three (3) Resident files reviewed were observed to be incomplete, Resident #1,2,3 did not have filled out needs and service plans (LIC 625) or Appraisals (LIC 603/A)deficiency issued. Last disaster drill was conducted on 7/7/26. Facility does not have liability insurance, deficiency issued. Based on observations and record review deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and these reports (LIC809/C, LIC 809D, LIC 811) and appeal rights were discussed and provided to Administrator Joi Mae Gubalane at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 15, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Administrator Joi Mae Gubalane and was granted entry to the facility. At the time of the visit there was two (2) staff present, and three (3) residents present. The facility is a four (4) bedroom, two (2), bathroom home, with a kitchen/dining area, living room, and attached garage. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (6) current census (6). LPA was accompanied by Facility Administrator, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside locked kitchen cabinet inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Joi Mae Gubalane.the state’s words, verbatim · CDSS document, Oct 14, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarina Ramirez made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator Joi Mae Gubalane and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6), a current census of (6). LPA Ramirez conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pool or similar bodies of water. Outdoor shaded area is sufficient for resident activities. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility is equipped with operating smoke detectors/carbon monoxide alarms and telephone service. Resident’s showers, toilets, and hand washing areas were operating properly. The hot water temperature in (2) residents bathrooms measured at 105.3 and 107.3 degrees F. Four (4) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, CCLD complaint poster, Ombudsman poster, facility license, disaster facility sketch, and residents rights. Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps and chemicals were kept locked and inaccessible to residents in care. Continuation on LIC – 809C: Care & Supervision: Facility has 24-hour/7days a week care staff. Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet. Record Review: Three (3) Staff files reviewed, staff #2 has missing CPR certificate, missing health screening, and missing training documentation; deficiency will be cited. Six (6) Resident files reviewed were observed to be complete. Based on observations and record review deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where reports (LIC809 & LIC809-D) were discussed and copies were provided with appeal rights to Administrator Joi Mae Gubalanethe state’s words, verbatim · CDSS document, Sep 18, 2024