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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336409176
Report Date: 06/30/2023
Date Signed: 06/30/2023 11:14:44 AM

Substantiated


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/28/2022 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220428084146
FACILITY NAME:LAKES, THEFACILITY NUMBER:
336409176
ADMINISTRATOR:TERRY RECORDSFACILITY TYPE:
740
ADDRESS:5801 SUN LAKES BLVDTELEPHONE:
(951) 845-2220
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:237CENSUS: 102DATE:
06/30/2023
ANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Executive Director Lori MatsushitaTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Staff failed to supervise resident resulting in resident wandering away from facility.
INVESTIGATION FINDINGS:
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On 06/30/2023 at 10:20 AM, Licensing Program Analyst (LPA) Melody Brown met with Executive Director (ED) Lori Matsushita at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegation. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

The investigation was conducted by LPA Melody Brown. The investigation consisted of records review and interviews with relevant parties. The allegation indicates that Staff failed to supervise resident resulting in resident wandering away from facility. LPA Brown obtained evidence to corroborate the allegation above. Residents' interviews indicated that staff failed to supervise a resident a week ago as a resident at the facility was able to wander away from the facility. Staffs interviews indicated that Resident #3 (R3) was able to get out of Memory Care as the left door was broken at that time. Staffs interviews revealed that there are times that the Memory Care locked do not work. *** Continuation in LIC9099C ***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
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 5
Control Number 56-AS-20220428084146
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
, CA 92507
FACILITY NAME: LAKES, THE
FACILITY NUMBER: 336409176
VISIT DATE: 06/30/2023
NARRATIVE
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Moreover, investigations revealed during the time of the incident at around 08:30 PM on 02/19/2022, the Memory Care staffs working that time did not even notice R3 was gone. One (1) staff reported was on their phone, another staff reported was doing dishes in the kitchen and the other staff reported was in medicine room. Memory Care staffs also reported that R3's wandering incident already happened previously. During the visit last 05/05/2022, Regional Marketing/Operations Director Lori Matsushita confirmed resident wandering incident on 03/01/2022 incident to LPA Brown and Staff #3 confirmed to LPA Brown R3's wandering incident on 02/19/2022. LPA Brown informed ED Matsushita that deficiency will be issued as this pose immediate health, safety and personal rights risks to residents in care.

Based on LPA Brown’s observations and records review, the preponderance of evidence standard has been met, and therefore the above allegation of Staff failed to supervise resident resulting in resident wandering away from facility is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. California Code of Regulations, (Title 22, Division 6 & Chapter 8) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, LIC9099, LIC9099D, and Appeal Rights were discussed and provided to ED Lori Matsushita..

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20220428084146
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
, CA 92507

FACILITY NAME: LAKES, THE
FACILITY NUMBER: 336409176
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2023
Section Cited
CCR
87705(l)(5)
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87705 Care of Persons with Dementia (l)The following initial and continuing requirements shall be met for the licensee to lock exterior doors...(6) Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision... This requirement is not met as evidenced by:
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Licensee stated to train all staffs on CCR 87705(l)(6) and submit proof of Training Log to LPA Brown by POC due date.

Licensee stated to submit signed Statement of Understanding on CCR 87705(l)(6) to LPA Brown by POC due date.
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Based on observation, interview and records review, the Licensee did not comply with the section cited above by failing to provide supervision to Resident #3 resulting to R3 wandering away from facility which pose immediate health, safety and personal rights risks to resident 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: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/28/2022 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220428084146

FACILITY NAME:LAKES, THEFACILITY NUMBER:
336409176
ADMINISTRATOR:TERRY RECORDSFACILITY TYPE:
740
ADDRESS:5801 SUN LAKES BLVDTELEPHONE:
(951) 845-2220
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:237CENSUS: 102DATE:
06/30/2023
ANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Executive Director Lori MatsushitaTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Resident sustained unexplained injuries while in care.
Smoke detectors in facility are non-operational.
INVESTIGATION FINDINGS:
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On 06/30/2023 at 10:20 AM, Licensing Program Analyst (LPA) Melody Brown met with Executive Director Lori Matsushita at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegations. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

The investigation was conducted by LPA Melody Brown. The investigation consisted of records review and interviews with relevant parties. The first allegation indicates that Resident sustained unexplained injuries while in care. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Residents' interviews indicated that there's no resident at the facility that sustained unexplained injuries while in care. Staffs’ interviews indicated that no residents at the facility sustained unexplained injuries while in care and there's no incident that happened at the facility that a resident sustained unexplained injuries. During the visit last 05/05/2022 and 06/22/2023, LPA Brown did not observe any resident with unexplained injuries.
*** Continuation in LIC9099C ***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20220428084146
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
, CA 92507
FACILITY NAME: LAKES, THE
FACILITY NUMBER: 336409176
VISIT DATE: 06/30/2023
NARRATIVE
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The second allegation indicates Smoke detectors in facility are non-operational. Interviews with residents indicated that they are not aware of an incident that happened at the facility of smoke detectors that are non-operational. Staffs’ interviews indicated that there's no incident of smoke detectors at the facility that are non-operational. Staffs interviews revealed that what was observed in the kitchen on 04/22/2022 at around 08:35 PM was a smoke from the grill top that was left on from the night time cook who left at 7:30 PM and when the caregiver saw the smoke coming from the kitchen at 08:10 PM, and the kitchen was locked and they cannot go in, 911 was called and they had to use the fire extinguisher to stop the small fire from the grill that was left on. The fire in the kitchen was not hot enough to engage the Ansul System which is connected to the fire panel in front of the facility and will trigger the smoke detectors at the facility. Moreover, investigations revealed that the facility had installed an "Ansul System" to extinguish fires that start in kitchens including grease fires and flammable liquids. During the visit last 05/05/2022, LPA Brown observed the facility's smoke detectors are operational, not in disrepair as all the smoke detectors at the facility are all interconnected at the fire panel in front of the facility. Per records review, LPA Brown observed that the City of Banning Office of the Fire Marshall in conjunction with the Riverside County Health Department has approved on 05/09/2022 full and unrestricted use of the facility's primary kitchen.

Based on the evidence, the allegation that Resident sustained unexplained injuries while in care (Allegation #1), Smoke detectors in facility are non-operational (Allegation #2) are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted where this report, LIC9099 was discussed and provided to Executive Director Lori Matsushita.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5