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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336409176
Report Date: 03/15/2024
Date Signed: 03/15/2024 01:52:46 PM


Document Has Been Signed on 03/15/2024 01:52 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: 109DATE:
03/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Lori Matsushita - Executive DirectorTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced case management visit to the facility to follow-up on an incident involving resident #1 (R1) and reported to Community Care Licensing Division Regional Office on 3/07/24. LPA met with Lori Matsushita, Executive Director, and discussed the purpose of the visit.
During today’s visit, LPA toured the facility and conducted interviews. LPA advised the Executive Director that this incident requires further investigation and possible follow-up telephone calls before the closure of this incident.

An exit interview was conducted where this report was discussed and a copy of the report was provided to the Executive Director at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
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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