336409176-9-24-2020-18-AS-NBRN-BTWTMP-20200929145125

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336409176
Report Date: 09/24/2020
Date Signed: 09/24/2020 02:59:02 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
09/03/2020 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200903160415

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: 105	DATE:	09/24/2020
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Lori Matsushita, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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-Facility staff do not have criminal record clearances
-Facility staff are not associated to the facility

INVESTIGATION FINDINGS:

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

During the course of this investigation LPA reviewed Licensing Information System Facility Personnel Report (LIS536), Provider Information Notice 20-9-CCLD, and interviewed two (2) employees. It is alleged that four (4) employees were not finger print cleared or associated to the facility. LPA learned the following information: Three (3) of the four (4) employees were verified to have a criminal record clearance and association to The Lakes through review of LIS536. One staff (S1) works for the corporation. It is noted through interviews conducted that S1 was present to consult and assist in hiring new employees, with scheduling, and conducting interviews in order to expedite hiring to meet facility need.

Unsubstantiated

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: 09/22/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2020

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-20200903160415

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: 09/24/2020

NARRATIVE

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S1 inventoried PPE, set up a couple isolation carts. According to their interview S1 did not provide resident care while in the facility. S1 does have a criminal record clearance in the State of Washington. Efforts were made to locate a Live Scan facility to obtain a criminal record clearance in the State of California, however, S1 returned to Washington before an appointment was scheduled. Due to COVID-19 the Live Scan office had closed and the San Bernardino was now the closest to schedule with.

Based on the information obtained through interview and review of applicable regulations and waiver set forth regarding criminal record clearances it appears that the facility remained within the parameters of Provider Information Notice 20-9-CCLD issued 04/02/2020. Although it appears that the facility is not out of compliance regarding the allegations of facility staff do not have criminal record clearances and facility staff are not associated to the facility, LPA is unable to verify the facility attempts to schedule to allocate a criminal record clearance for S1 and therefore, 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 the facility representative telephonically via facetime and a copy is being provided via email.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2020

LIC9099 (FAS) - (06/04)

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