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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336409176
Report Date: 04/28/2023
Date Signed: 05/09/2023 10:25:50 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
11/10/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211110141321
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
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Director of Nursing Glenda De LeosTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff do not provide outside activities for residents.
INVESTIGATION FINDINGS:
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On 05/09/2023 at 09:45 AM, Licensing Program Analysts (LPAs) Melody Brown and Mary Rico made an unannounced visit to the facility to amend the complaint findings delivered last 04/28/2023. LPAs Brown and Rico were granted entrance at the reception area by a staff and LPAs Brown and Rico explained the purpose of the visit. Staff contacted Director of Nursing (DON) Glenda De Leos to assist LPAs Brown and Rico. The investigation consisted of review of medical records, file review, interviews with staff and residents as well as observation.

The allegation indicates Staff do not provide outside activities for residents. The investigation was conducted by LPA Brown. LPA Brown toured the facility, conducted interviews, and reviewed facility files. Interviews with staffs and residents indicated that the facility has no consistent activities for residents. Moreover, interviews revealed that the activity staff just sits at the office and not do an activity for the residents 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. *** Continuation in LIC9099C ***
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
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 6
Control Number 18-AS-20211110141321
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: 04/28/2023
NARRATIVE
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Based on residents and staffs interviews and record reviews, LPA Brown determined that the allegation Staff do not provide outside activities for residents is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted with Director of Nursing Glenda De Leos where this report, LIC9099, LIC9099D, and Appeal Rights were discussed and provided.

*** This is an Amendment of LIC9099 Issued last 04/28/2023 ***

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 18-AS-20211110141321
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: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2023
Section Cited
CCR
87705(c)(7)
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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (7) An activity program shall address the needs and limitations of residents with dementia...This requirement is not met as evidenced by:
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Licensee stated to submit signed Statement of Understanding on CCR 87705(c)(7) to LPA Brown by POC due date.
Licensee stated to submit current Activity Calendar for the facility 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 an activity program for the residents at the facility which pose potential health, safety and personal rights risks to residents in care.
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CCR
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Licensee stated to submit signed Statement of Understanding on CCR 87705(c)(7) to LPA Brown by POC due date.
Licensee stated to submit current Activity Calendar for the facility and submit to LPA Brown by POC due date.
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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: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
11/10/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211110141321

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
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Director of Nursing Glenda De LeosTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident sustained unexplained fractures while in care.
Staff did not ensure resident's hydration needs were being met
Staff are not assisting residents with incontinence needs
Resident's room smell malodorous
Staff did not clean resident's room
Staff did not safeguard residents personal belongings
INVESTIGATION FINDINGS:
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On 05/09/2023 at 09:45 AM, Licensing Program Analysts (LPAs) Melody Brown and Mary Rico made an unannounced visit to the facility to amend the complaint findings delivered last 04/28/2023. LPAs Brown and Rico were granted entrance at the reception area by a staff and LPAs Brown and Rico explained the purpose of the visit. Staff contacted Director of Nursing (DON) Glenda De Leos to assist LPAs Brown and Rico. The investigation consisted of review of medical records, file review, interviews with staff and residents as well as observation.

The first allegation indicates Resident sustained unexplained fractures while in care. Based on the evidence collected during the investigation, LPA Brown determined that there was no corroborating evidence to support that there was staff neglect that resulted in R1 sustaining fractures while in care. Documents review revealed that there are two (2) night caregivers working on the time of the incident and one (1) Medical Technician (MedTech) and R1 was appropriately sent to the hospital for medical care needed. *** Continuation in LIC9099C ***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
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 6
Control Number 18-AS-20211110141321
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: 04/28/2023
NARRATIVE
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Interviews with residents and staffs indicated staffs are providing care and supervision to residents in care.

The second allegation indicates Staff did not ensure resident's hydration needs were being met. Resident interviews indicated that staffs check on them every two (2) hours to ensure that their hydration needs were met. Staffs’ interviews revealed that they are checking on residents every (2) hours to make sure that they are hydrated and also to check if they are needing assistance or if they need help. Interviews with residents and staffs revealed that no incident happened at the facility that a staff did not ensure a residents' hydration need is not met.

The third allegation indicates Staff are not assisting residents with incontinence needs. Residents interviews indicated staffs are checking on them if they needed to be changed every two (2) hours and no incident happened at the facility where staff did not check on them. Staff interviews indicated that they are checking on residents if residents needed to be changed every two (2) hours or more if needed and no incident happened at the facility that a staff did not assist a resident on incontinence needs.



The fourth allegation indicates Resident's room smell malodorous. Residents interviews indicated their rooms were not malodorous and no incident happened at the facility were a resident reported that their room is malodorous. Staff interviews indicated that no residents reported their room's malodorous and no incident happened at the facility that their room is malodorous.

The fifth allegation indicates Staff did not clean resident's room. Residents interviews indicated that staffs at the facility are cleaning their rooms. Residents reported that staffs are picking up their trash, tidying up their room, fixing their bed and changing their bed sheets. Residents interviews also revealed that they observed a housekeeper at the facility that cleans their room regularly and no incident happened at the facility that staff did not clean their room. Staffs interviews indicated that they are cleaning the residents room and no incident happened at the facility that a staff did not clean a resident room.



*** Continuation in LIC9099C ***
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20211110141321
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: 04/28/2023
NARRATIVE
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The sixth allegation indicates Staff did not safeguard residents personal belongings. Residents interviews indicated staffs are making sure that their personal belongings are safe in their rooms. Also, residents interviews revealed that if they misplaced their personal belongings, staffs always returned it to them and there's no incident happened at the facility where staff did not safeguard their personal belongings. Staffs interviews indicated that they safeguard residents personal belongings. Staffs interviews revealed that at night, they are collecting residents eyeglasses and hearing aids and in the morning they are returning it to the residents to make sure that the eyeglasses and the hearing aids were not misplaced. Staffs interviews also indicated that no incident happened at the facility that a staff did not safeguard a resident personal belongings.

Based on the evidence, the allegation that Resident sustained unexplained fractures while in care (Allegation #1), Staff did not ensure resident's hydration needs were being met (Allegation #2), Staff are not assisting residents with incontinence needs (Allegation #3), Resident's room smell malodorous (Allegation #4),Staff did not clean resident's room (Allegation #5), Staff did not safeguard residents personal belongings (Allegation #6) 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 allegations are unsubstantiated at this time.

An exit interview was conducted, and a copy of this report (LIC9099) was discussed and provided to Director of Nursing Glenda De Leos.

*** This is an Amendment of LIC9099 Issued last 04/28/2023 ***

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6