336409176-8-3-2020-18-AS-NBRN-BS6V3J-20200804160447

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336409176
Report Date: 08/03/2020
Date Signed: 08/03/2020 03:21:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/03/2020 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200703091622

FACILITY NAME:	LAKES, THE		FACILITY NUMBER:	336409176
ADMINISTRATOR:	LORI MATSUSHITA		FACILITY TYPE:	740
ADDRESS:	5801 SUN LAKES BLVD		TELEPHONE:	(951) 845-2220
CITY:	BANNING	STATE: CA	ZIP CODE:	92220
CAPACITY:	237	CENSUS: 121	DATE:	08/03/2020
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Lori Matsushita, Administrator		TIME COMPLETED:	09:00 AM

ALLEGATION(S):

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Admission Agreement includes deceptive information about the license.

INVESTIGATION FINDINGS:

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This visit conducted by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegation mentioned above. The visit is being conducted through facetime due to COVID-19 and necessary precautionary measures.

During the course of the investigation LPA interviewed the facility administrator, LPA requested information regarding the corporate structure, a review of the facility file was completed and included review of the admission agreement and form LIC 309, Administrative Organization. Review of the information obtained regarding the allegation of admission agreement includes deceptive information about the license revealed the following information:

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200703091622

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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, THE	FACILITY NUMBER: 336409176
	VISIT DATE: 08/03/2020

NARRATIVE

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Senior Management Services, LLC is listed on Administrative Organization form (LIC 309) on page one (1), in section one (1) and is identified as the Corporation/Limited Liability Company (LLC). Section eight (8) identifies ownership/interest in the corporation or LLC as follows: The Gene E. Lym Trust effectively owns 100% of Senior Management Services, LLC through a 10% direct ownership, 89% indirect ownership through Chuckar Corp and 1% indirect interest through Careage Health Care of Washington. Careage Health Care of Washington is listed on page two (2), section eleven (11) as All Directors (Corporations)/Managers and Managing Members of the Senior Management Services LLC. Page six (6) of the facility The Lakes Residence and Care Agreement identifies Senior Management Services, LLC as the licensee. It is also alleged that Careage, Inc. had it’s license forfeited by the CA FTB, however the organization on record is noted as Careage Healthcare of Washington, INC and are identified as the corporations managing members. Search of the California Secretary of State business search portal found that Careage Healthcare of Washington, INC has remained active since 1992.

Based on the aforementioned information this agency has found the complaint allegation is are unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

A copy of this report is being reviewed with, and furnished to the facility representative via email.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2020

LIC9099 (FAS) - (06/04)

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