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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336409176
Report Date: 10/07/2022
Date Signed: 10/07/2022 02:46:35 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/12/2020 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201112124123
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: 25DATE:
10/07/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff is not providing wound care to residents
Medication errors
Staff are not supervising residents adequately resulting in falls
INVESTIGATION FINDINGS:
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This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegations mentioned above.

During the course of this investigation LPA interviewed five (5) employees and met with five (5) residents of the memory care area. LPA reviewed five (5) of twenty five (25) resident records and looked at five (5) of (25) resident medication records. Investigation revealed the following information:

These alleged violations are specific to the memory care portion of the facility. It is alleged that the residents are not being given medications according to order.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20201112124123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: LAKES, THE
FACILITY NUMBER: 336409176
VISIT DATE: 10/07/2022
NARRATIVE
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 LPA review of medication records did not reveal any discrepancies for dispensing when cross referenced with their medication logs and orders. It is alleged that staff are not supervising residents adequately resulting in falls. LPA review of staffing schedules and review of incident reports and logs do not indicate a trend that staffing or lack of supervision are contributing factors to increased falls. Five (5) out of five (5) staff interviewed deny an increase of resident falls. Five (5) of five (5) staff interviewed understand the requirement that wound care is to be provided by a skilled professional, however, that during the mandatory quarantine for COVID-19 pandemic that staff did provide bandage changes in the absence of hospice care personnel in the facility through the pandemic.

Based on the available information we have found the complaint allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

A copy of this report is being reviewed with and furnished to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2