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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336409176
Report Date: 03/26/2021
Date Signed: 03/26/2021 11:59:09 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
03/18/2021 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210318110040
FACILITY NAME:LAKES, THEFACILITY NUMBER:
336409176
ADMINISTRATOR:TERRY RECORDSFACILITY TYPE:
740
ADDRESS:5801 SUN LAKES BLVDTELEPHONE:
(951) 845-2220
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:237CENSUS: DATE:
03/26/2021
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Terry Records, Executive DirectorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Residents pull cord is in disrepair
Staff are not meeting residents needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Goldenberg arrived to the facility to initiate the 10 day visit to investigate the above noted allegations. LPA met with Executive DirectorTerry Records.

During this visit LPA interviewed the facility administrator, obtained and reviewed a copy of a 60 day notice for care increase, a copy of the new fee schedule, one purchase order for a nurse call system, and email confirmation of installation dates. Based on review of the aforementioned LPA learned the following: In regard to the allegation that the pull cord is in disrepair, the facility call system failed and became inoperable on 03/16/2021. On 03/22/2021 a new nurse call system was purchased and email details reveal that installation dates are scheduled 04/06/2021, 04/07/2021, 04/08/2021, and 04/09/2021.
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: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
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 4
Control Number 18-AS-20210318110040
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: 03/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/26/2021
Section Cited
CCR
87303(i)(1)(b)
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All facilities licensed for 16 or more... shall have a signal system which shall: Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal...
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Plan of Correction is for replacement of nurse call system to begin 04/06/21, increase in staff through an agency to make direct observation of residents at least every hour and as needed
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The facility failed to maintain the requirement of this regulation as evidenced by a failed nurse signal system since 03/16/2021.This poses a potential risk to the health and safety of residents in care.
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 for those requiring more. Residents continue to contact staff using their telephone to access assistance. This plan of correction is acceptable and the POC is cleared.
Type B
03/26/2021
Section Cited
CCR
87468.1(a)(2)
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Residents in all residential care facilities for the elderly shall have ... To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Plan of Correction is for replacement of nurse call system to begin 04/06/21, increase in staff through an agency to make direct observation of residents at least every hour and as needed
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The facility failed to maintain the requirement of this regulation as evidenced by a failed nurse signal system since 03/16/2021. This poses a potential risk to the health and safety of residents in care.
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 for those requiring more. Residents continue to contact staff using their telephone to access assistance. This plan of correction is acceptable and the POC is cleared.
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: 03/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
03/18/2021 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210318110040

FACILITY NAME:LAKES, THEFACILITY NUMBER:
336409176
ADMINISTRATOR:TERRY RECORDSFACILITY TYPE:
740
ADDRESS:5801 SUN LAKES BLVDTELEPHONE:
(951) 845-2220
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:237CENSUS: DATE:
03/26/2021
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Terry Records, Executive DirectorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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9
Resident charged additional charge for basic service
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Goldenberg arrived to the facility to initiate the 10 day visit to investigate the above noted allegations. LPA met with Executive DIrector Terry Records. During this visit LPA interviewed the facility administrator, obtained and reviewed a copy of a 60 day notice for care increase, a copy of the new fee schedule, one purchase order for a nurse call system, and email confirmation of installation dates. Based on review of the aformentioned LPA learned the following: Sixty (60) day notice for care increase was delivered to all residents on 12/31/2021 along with an attached fee schedule. It is alleged by R1 that an additional charge for cleaning the carpets was applied that should be included in the basic services. Interview of the Executive Director revealed that the facility has waived these fees for R1 and have been doing the carpets at no charge. We have found the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. A copy is being provided to Executive Director Terry Records.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20210318110040
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: 03/26/2021
NARRATIVE
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It is alleged that on 3/18/2021 a resident needs were not being met as a result of their pendant call system failure. Based on the information that the call system failure occurred on 03/16/2021 and the preponderance of information suggests that on 03/18/2021, as reported, R1 did not have staff respond to their call for assistance as needed.

We have substantiated the complaint allegations as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to Terry Records, Executive Director
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4