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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530266
Report Date: 03/19/2025
Date Signed: 03/19/2025 11:08:55 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO 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
03/12/2025 and conducted by Evaluator Sarina Ramirez
COMPLAINT CONTROL NUMBER: 56-AS-20250312144905
FACILITY NAME:LAKES, THEFACILITY NUMBER:
335530266
ADMINISTRATOR:MATSUSHITA, LORIFACILITY TYPE:
740
ADDRESS:5801 SUN LAKES BLVDTELEPHONE:
(915) 845-2220
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:276CENSUS: 111DATE:
03/19/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Business Office Manager Araceli PetersTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident pushed by unknown person.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegation. LPA met with Business Office Manager Araceli Peters, and discussed the purpose of the visit.

Interviews conducted with staff, resident, and outside parties revealed that on 3/12/25, Resident 1 (R1) wandered into another resident’s room attempting to use the restroom. Resident 2 (R2) noticed R1 in their room and became agitated, resulting in pushing R1 to leave from their restroom/room. Staff intervened and R1 was taken to the doctor/hospital and returned to the facility the same day with a head hematoma.

R1 was unavailable to be interviewed, due to sleeping. Staff informed LPA, R1 does not like to be woken up too early. Based on observation, interviews with facility staff and resident the allegation is unsubstantiated. An Unsubstantiated complaint means, that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
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 56-AS-20250312144905
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: LAKES, THE
FACILITY NUMBER: 335530266
VISIT DATE: 03/19/2025
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
26
27
28
29
30
31
32
An exit interview was conducted with Business Office Manager Araceli Peters and a copy of this report was provided to Business Office Manager at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2