336409176-2-7-2023-18-AS-NBRN-CNVPF4-20230209101607

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336409176
Report Date: 02/07/2023
Date Signed: 02/07/2023 12:06:17 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
09/25/2020 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200925112916

FACILITY NAME:	LAKES, THE		FACILITY NUMBER:	336409176
ADMINISTRATOR:	LORI MATSUSHITA		FACILITY TYPE:	740
ADDRESS:	5801 SUN LAKES BLVD		TELEPHONE:	(951) 845-2220
CITY:	BANNING	STATE: CA	ZIP CODE:	92220
CAPACITY:	237	CENSUS: 90	DATE:	02/07/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Lori Matsushita, Executive Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff not properly preparing food for resident
Staff not providing adequate food service

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.

This investigation consisted of review of one (1) resident records (S1), review of the process for provision of modified diets, review of food supply, food storage and food orders. LPA interviewed the Food Service Director and the Executive Director. It is alleged that following oral surgery R1 was not provided the diet ordered by their dentist and that the food they were served was cold and had expired. Investigation revealed the following:

Review of R1's record did not reveal any modified diet order during the time in question. Interviews revealed that the practice of the facility is to follow modified diets as ordered.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200925112916

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: 02/07/2023

NARRATIVE

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The kitchen keeps a list of resident with special diet orders and their foods are prepared as ordered. The Food Service Director provides lists to the kitchen staff. They receive the orders from the Director of Nursing. The list is updated as needed. Interviews revealed that lists are replaced as needed but old ones are not retained. LPA review of the food supply and a random sampling of expiration dates on foods slated for meal services, observation of the AM food service, observation in the kitchen, assessment of the food supply, R1's orders, R1's progress notes dated 9/20/2020, and interviews conducted did not support or refute the allegations as reported.

We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is 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: 02/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC9099 (FAS) - (06/04)

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