336409176-11-29-2022-18-AS-NBRN-CNTPSC-20230207103409

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336409176
Report Date: 11/29/2022
Date Signed: 11/29/2022 02:02:31 PM

Unsubstantiated

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
08/03/2020 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200803085106

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: 94	DATE:	11/29/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Lori Matsushita, Executive Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff neglect led to resident sustaining pressure injuries
Staff failed to assist residents in a timely manner

INVESTIGATION FINDINGS:

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This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegations mentioned above.

During the course of the investigation, interviews were conducted with residents, staff, a review of resident records was completed and copies of pertinent documents were obtained. Investigation revealed the following: Review of the facility progress notes for R1 indicate that R1 had a personal caregiver. R1 uses a personal mobility scooter. R1 received incontinent care. R1 would call for assistance as needed. Interviews revealed that R1 would refuse services occassionally. Progress notes indicate medication and care refusals. R1 was receiving home health services for concerns of rash associated with UTI and leg injury from a fall. Review of R1 records revealed that R1 developed a sore on their bottom 5/17/20 which was being followed by home health nurses.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

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-20200803085106

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: 11/29/2022

NARRATIVE

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There is no substantiating evidence leading to neglect of the resident as the cause for sustaining pressure injuries. Records revealed R1 was on fall precautions and it is facility policy that residents are checked on twice per shift and as needed. R1 was capable of utilizing the staff alert system. Review of call logs for the week of 08/24/2020 through 8/31/2020 did not reveal any evidence to validate residents are not assisted in a timely manner. Interview with staff revealed that the facility has two methods of calling for assistance. Residents can, for an extra fee, wear a call pendant necklace and also there are pull cords and push button call systems in each resident room. A pull cord is located in each resident restroom. Some of the units have push button call box in the studios on the wall. The alert system notifies the front desk and the front desk personnel will notify the assigned caregivers with a walkie talkie. Seven (7) of seven (7) residents interviewed expressed satisfaction with the facilities services and call response times.

We have found the complaint allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

LIC9099 (FAS) - (06/04)

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