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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336409176
Report Date: 11/05/2020
Date Signed: 11/05/2020 04:17:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
336409176
ADMINISTRATOR:LORI MATSUSHITAFACILITY TYPE:
740
ADDRESS:5801 SUN LAKES BLVDTELEPHONE:
(951) 845-2220
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:237CENSUS: DATE:
11/05/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:TIME COMPLETED:
01:46 PM
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Lcensing Program Analyst (LPA) Kathleen Wiggins contacted the facility via telephone to commence a case management visit via telephone due to COVID-19. LPA identified herself and discussed the purpose of the call with Business Office Manager - Karla Espinoza..

Based on evidence obtained during today's visit, the LPA has verified that the individual is not present, employed, or residing at the facility. The individual named in the Confirmation of Removal letter dated 10/05/2020 is Alfred Delagarza.

LPA was informed by the Community Business Manager that Delagarza applied to work at the facility and was pending background check clearance. Due to COVID it was taking a long time for the clearance to come back. The administrator stated she understood that during this process Delagarza cannot work, reside, or be present at a licensed facility.

No deficiencies were cited during this visit. An exit interview was conducted with the administrator via telephone and copies of this report and Non-Exemptible conviction letter were provided to the Community Business Manager via email. Report with facility representative signature was obtained. Verification of removal is complete.

SUPERVISOR'S NAME: Leslie MendivelesTELEPHONE: (951) 248-2222
LICENSING EVALUATOR NAME: Kathleen WigginsTELEPHONE: (951) 205-7142
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
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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