336409176-12-6-2024-56-AS-EMAN-DDCMWF-20250128085813

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336409176
Report Date: 12/06/2024
Date Signed: 12/06/2024 02:16:23 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
07/03/2024 and conducted by Evaluator Paola Guerrero

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20240703084511

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: 99	DATE:	12/06/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Mercede Cristina Ceballos-Direcor		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Licensee does not ensure staff are adequately trained
Facility staff are not properly supervising residents who are a fall risk
Facility did not report injury to resident’s authorized representative
Licensee does not ensure facility is adequately staffed to meet resident's medication needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Director Mercede Cristina Ceballos and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records.

First allegation: Licensee does not ensure staff are adequately trained. Regarding the allegation “Licensee does not ensure staff are adequately trained” LPA conducted a record review pertaining to the allegation stated above during the review of records (med-tech job duties), LPA discovered that Med-techs job duties do not entail checking residents blood pressure and/or monitoring residents sugar levels. LPA observed facility staff roster and discovered that facility utilize Certified Nursing Assistants (CNAs), that support residents with their basic medical needs throughout different shifts. Furthermore, throughout review of records LPA discovered that all caring support staff have sustained and completed the proper eligibility trainings to provide residents with proper care.

Second allegation: Facility staff are not properly supervising residents who are a fall risk.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

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 56-AS-20240703084511

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/06/2024

NARRATIVE

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Regarding the allegation stated above, LPA requested documentation pertaining to the allegation stated above. Upon reviewing documentation LPA discovered that had three residents receiving personalized care services depending on each resident care needs. LPA interviewed Resident #1 who sustained an accidental fall in the dining area resulting in no injuries about three weeks ago. Resident #1 informed LPA that enough supervision was around that was able to assist resident right away. LPA collected facilities most current staff roster and observed that the facility has an adequate number of staff support on each shift (AM, PM, NOC, and “LD” Late duty), to meet resident care needs.

Third allegation: Facility did not report injury to resident’s authorized representative. Regarding the allegation “Facility did not report injury to resident’s authorized representative” LPA conducted interview with Resident #2 who informed LPA about an accidental fall resident sustained outside of facility parking lot. R#1 informed that resident responsible party was present during the time off the fall. R#1 stated to LPA that resident was transported to hospital. LPA conducted a record review and discovered that a special incident report (SIR), was faxed to Community Care Licensing (CCL), Regional office.

Fourth Allegation: Licensee does not ensure facility is adequately staffed to meet resident's medication needs. Regarding the allegation stated above, LPA conducted interview with residents pertaining to the allegation “Licensee does not ensure facility is adequately staffed to meet resident's medication needs” Five out of Five residents reported to LPA not having any issues or concerns when it comes to their dispense of medication. In addition, Five out of five residents reported to LPA about receiving their medication on time. Five out of Five resident reported not having any concerns regarding staff not meeting their medication needs. LPA collected facilities most current staff roster and observed that the facility has an adequate number of staff support on each shift (AM, PM, NOC, and “LD” Late duty), to meet resident needs. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated.

Unsubstantiated: meaning that 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.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Director Mercede Cristina Ceballos at the end of the visit.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC9099 (FAS) - (06/04)

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