336409176-10-22-2024-56-AS-SRAZ-DAARXR-20241022132512

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336409176
Report Date: 10/22/2024
Date Signed: 10/22/2024 01:25:21 PM

Document Has Been Signed on 10/22/2024 01:25 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

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: 101	DATE:	10/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Executive Director Lori Matsushita		TIME COMPLETED:	01:35 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Sarina Ramirez and Mary Rico made an unannounced visit to the facility to conduct a required annual inspection. LPAs met Executive Director Lori Matsushita, and discussed the purpose of the visit. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (237), and a current census of (101). LPAs conducted a general inspection of facility, which included, but was not limited to, the following:

Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has a swimming pool that is enclosed and locked inaccessible to residents in care. The facility has sufficient space for resident activities. Eleven (11) resident bedrooms were inspected. Eleven (11) resident’s bathrooms were inspected, hot water temperatures measured from 104 to 110 degrees F. The facility is equipped with operating smoke/carbon monoxide alarms, the facility was recently inspected by the Fire Department on 5/20/24. Facility has operating laundry equipment, and telephone service. The facility has posted in a common area, personal rights, facility sketch, the Community Care Licensing complaint poster, Ombudsman poster, menu, activities, and license. Cleaning supplies and sharps were kept inaccessible to residents in care.

Food Service: Kitchen and dining areas were maintained cleaned. Non-perishable and perishable food supply is sufficient for number of residents in care. Facility refrigerators and freezers were maintained in operating condition. The facility has posted a monthly menu.

Health Related services: LPA Ramirez reviewed (6) resident medications. Resident’s medications are labeled and centrally stored in a locked cabinet.

Record Review: Ten (10) resident files reviewed were observed to be complete. Ten (10) staff files reviewed were observed to be incomplete, all staff files reviewed had missing CPR certificates, deficiency will be issued. The Administrator’s certification is current. The facility has an emergency and disaster plan on file; last disaster drill was completed on 6/20/24.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Sarina Ramirez	TELEPHONE: (951) 248-0307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024

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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Document Has Been Signed on 10/22/2024 01:25 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LAKES, THE	FACILITY NUMBER: 336409176
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the Executive Director did not comply with the section cited above by not having CPR certificates in staff files which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/23/2024
	Plan of Correction
1 2 3 4	Executive Director stated she will submit proof of certificates to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Sarina Ramirez	TELEPHONE: (951) 248-0307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024

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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LAKES, THE	FACILITY NUMBER: 336409176
	VISIT DATE: 10/22/2024

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Based on LPAs observations and records reviewed, deficiency will be cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report (LIC809) and LIC 809D was discussed to Executive Director Lori Matsushita . Copies of the reports were provided with appeal rights to the Executive Director at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Sarina Ramirez	TELEPHONE: (951) 248-0307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024

LIC809 (FAS) - (06/04)

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