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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336409176
Report Date: 06/24/2020
Date Signed: 06/25/2020 08:12:12 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:LAKES, THEFACILITY NUMBER:
336409176
ADMINISTRATOR:LORI MATSUSHITAFACILITY TYPE:
740
ADDRESS:5801 SUN LAKES BLVDTELEPHONE:
(951) 845-2220
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:237CENSUS: 126DATE:
06/24/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Lori Matsushita, AdministratorTIME COMPLETED:
11:06 AM
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Licensing Program Analyst Deborah Mullen made contact with Lori Matsushita, Administrator, to discuss and review the current Admissions Agreement. Contact was made by telephone due to COVID 19. The facility corrected page 8, section 15, of the admissions agreement to comply with requirements as stated in Health and Safety Code 1569.658(a)(b). LPA advised the administrator the updated admissions agreement has been accepted. No deficiency cited at this time.

This report was discussed with Ms. Matsushita, with a copy emailed for her review and signature
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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