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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336409176
Report Date: 01/14/2021
Date Signed: 01/14/2021 11:56:49 AM



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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/13/2020 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200513100852
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:
01/14/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Terry Records, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility not abiding by plan of operation.
INVESTIGATION FINDINGS:
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Amy Goldenberg, Licensing Program Analyst (LPA), is conducting this visit to conclude this agency’s investigation into the complaint allegation mentioned above. This visit is being conducted telephonically due to COVID-19 precautionary measures.

During the course of this investigation LPA reviewed the facility admission agreement and plans of operations in place prior to July 1 2019 and LPA conducted two (2) resident interviews before concluding. It is alleged that the facility is not abiding by the plan of operations. According to the plan of operations reviewed the administrator will call on residents on the day after moving in to assess resident satisfaction and a one-month resident status review will be made to ensure all resident needs are assessed.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2021
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 3
Control Number 18-AS-20200513100852
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
RIVERSIDE, CA 92507
FACILITY NAME: LAKES, THE
FACILITY NUMBER: 336409176
VISIT DATE: 01/14/2021
NARRATIVE
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Two (2) of Two (2) residents interviewed corroborated each other in that it is known that on at least two occasions prior to July 1, 2019 the administrator did not follow the plan of operations as it was approved.

We have substantiated the complaint allegation as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this LIC 9099, 9099D and appeal rights are being reviewed with the facility representative and a copy is being provided via email.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20200513100852
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
RIVERSIDE, CA 92507

FACILITY NAME: LAKES, THE
FACILITY NUMBER: 336409176
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2020
Section Cited
CCR
87208(a)
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Plan of Operation: Each facility shall have and maintain a current, written definitive plan of operation...The facility failed to meet this requirement as evidence by the following:
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 It is noted that these items were removed from the plan of operations and have been approved by Community Care Licensing. POC cleared.
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2 of 2 residents interviewed corroborated each other in that it is known that on at least two occasions prior to July 1, 2019 the administrator did not follow the plan of operation as alleged.
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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: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3