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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336409176
Report Date: 06/02/2021
Date Signed: 06/02/2021 02:09:35 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:TERRY RECORDSFACILITY TYPE:
740
ADDRESS:5801 SUN LAKES BLVDTELEPHONE:
(951) 845-2220
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:237CENSUS: 100DATE:
06/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:26 PM
MET WITH:Terry RecordsTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Pauline Beschorner arrived at the facility on June 2, 2021 at 12:26 PM to conduct an Annual/Required Visit. Upon LPA arrival, LPA's temperature was checked at the entrance and LPA signed in with the system utilized by the facility. The system requires each visitor to answer all COVID related questions. LPA met with Executive Director Terry Records. LVN caregiver, Jessica Maldonado accompanied LPA on a tour of the inside and outside of the facility and the following was observed:

All staff are wearing a surgical mask while working at the facility. LPA observed 2 chairs at each table in the dining area and 2-3 residents eating at the dining tables. Entertainment is offered in the facility in the lobby area on Wednesday's and Friday's. All entertainers who come to the facility are vaccinated. The facility spread the furniture out to allow for social distancing and all residents wear a mask.

Director of Nursing Glenda DeLeos is assigned as the Infection Control Person. DeLeos is assigned to provide staff with all of the staff trainings, proper donning and doffing of PPE and monitoring to be sure all staff and resident temperatures are taken and documented. Staff temperatures are checked daily upon entrance into the facility and resident temperatures are checked at least one time per day or as needed. When the resident leaves the building the residents temperature is checked when they reenter the building.

LPA observed the facility has at least a 30-day supply of PPE and all infection control procedures are being followed. An exit interview was conducted and a copy of this report was provided to Executive Director Terry Records. No citations or technical violations are being issued at this time.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
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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