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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336409176
Report Date: 04/28/2023
Date Signed: 04/28/2023 02:22:24 PM


Document Has Been Signed on 04/28/2023 02:22 PM - It Cannot Be Edited

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
, CA 92507



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:
04/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Director of Nursing Glenda De LeosTIME COMPLETED:
02:30 PM
NARRATIVE
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On 04/28/2023, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to to initiate a Case Management - Deficiency. LPA Brown met with Director of Nursing (DON) Glenda De Leos and explained the purpose of the Case Management Deficiency Visit.

LPA Brown requested Resident #1 (R1) facility documents but DON Glenda De Leos reported to LPA Brown that R1 facility documents cannot be found and unavailable at the facility. LPA Brown informed DON De Leos that deficiency will be issued as this pose potential health, safety and personal rights risks to resident in care.

An exit interview was conducted where this report LIC809, LIC809D and Appeal Rights were discussed and provided to Director of Nursing Glenda De Leos.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
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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Document Has Been Signed on 04/28/2023 02:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2023
Section Cited

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87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if...This requirement is not met as evidenced by:
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Licensee stated to submit signed Statement of Understanding on CCR 87506(d) and submit 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 not having R1's record available at the facility for licensing agency to review during the facility visit which pose potential health, safety and personal rights risks to residents 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.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
LIC809 (FAS) - (06/04)
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