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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336409176
Report Date: 09/12/2023
Date Signed: 09/12/2023 01:38:41 PM


Document Has Been Signed on 09/12/2023 01:38 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:LAKES, THEFACILITY NUMBER:
336409176
ADMINISTRATOR:LORI MATSUSHITAFACILITY TYPE:
740
ADDRESS:5801 SUN LAKES BLVDTELEPHONE:
(951) 845-2220
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:237CENSUS: 120DATE:
09/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lori Matsushita, AdministratorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at The Lakes at Banning unannounced to conduct an Annual Inspection. LPA walked in and used the kiosk to sign in as advised. LPA introduced self and stated purpose of the visit. LPA met with Administrator, Lori Matsushita; who also provided LPA with a tour of the facility. LPA Coleman conducted a tour of the facility, inside and outside, and observed the following:

Facility: The Facility is licensed for two hundred thirty-seven (237) non ambulatory, twenty four, (24) bedridden, thirty (30) Hospice and delayed egress within the Memory Care Unity. LPA Coleman observed that the facility is operating at the capacity and in the conditions approved by Community Care Licensing (CCL).


Physical Plant: LPA Coleman observed the facility's temperatures to be comfortable. The lighting and lamps make for appropriate lighting to ensure residents comfort and safety. The facility is equipped with smoke alarms, carbon monoxide detectors and fire extinguishers which are operable, and the facility was recently inspected by the Fire Department (August 2023), who determined that the facility was safe and operating as required. LPA Coleman reviewed the facility's Emergency Disaster Plan and Fire Drills and observed that the facility last conducted a Fire Drill on August 2023. LPA observed a pool on facility grounds. The pool included a secure fence around the perimeter. According the Administrator, residents are to inform staff of their intent to swim so that staff can accompany them to ensure safety.

Food Service: Nonperishable and perishable food is sufficient for number of residents in care. Food is being prepared and stored properly. Facility has a variety of food available for residents. Staff keep track of special dietary requirements as prescribed within the kitchen’s secure office. LPA observed that although the kitchen is secure, sharps and chemical are also kept secure inaccessible to residents.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: LAKES, THE
FACILITY NUMBER: 336409176
VISIT DATE: 09/12/2023
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Care & Supervision: Facility has sufficient care staff; who assist residents 24 hours and 7 days a week. According to staff records, all staff files contained verification of their annual trainings.
Record Review and Resident/Staff Files: LPA Coleman reviewed records for fifteen, (15) residents currently living at the facility. Resident records are complete with physician reports and Needs and Services Plans. Out of 15 resident files, 2 residents did not have updated Physician’s Reports. LPA Colvin additionally reviewed five (5) staff files and confirmed that staff records reflect current CPR/First Aid Certification and Criminal Record Clearance. The Administrator's Administrator Certificate was observed in compliance.
Administration: Disaster Plan, Ombudsman poster, Administrator Certificate, Personal Rights and facility license are posted in the hallway of the facility. Emergency Disaster Plan is current.
Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored and locked in a file cabinet in nurse station. LPA reviewed 15 of the residents' medication lists. Centrally Stored Medication Log. LPA Coleman did not observe any medication errors at this time.

No deficiencies were cited during this inspection. Technical Violations will be issued to address concerns for the documentation. Exit interview conducted and copy of this report was provided to Administrator/Licensee Lori Matsushita.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC809 (FAS) - (06/04)
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