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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336409176
Report Date: 06/02/2021
Date Signed: 06/02/2021 04:06:26 PM



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
04/22/2021 and conducted by Evaluator Pauline Beschorner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210422090435
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
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Terry RecordsTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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9
Staff did not follow physician's orders
Staff did not meet resident's hygiene needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pauline Beschorner conducted an unannounced complaint visit in order to deliver findings for the above complaint allegations. LPA met with Executive Director Terry Records.

The first allegation alleges staff did not follow physician's oders. Based on record review R1 was diagnosed with dehydration in August 2020. In October 2020, resident was taken to the emergency room where R1 was diagnosed with dehydration for a second time in 3 months. During this visit R1 was prescribed to be given at least 2 (two) liters of oral fluids daily. Per the Activities of Daily Living Sheet (ADL) R1 took fluids and/or a snack but it is not documented how much fluids were provided to R1. LPA observed the water log hanging in R1's room for October 5, 2020 where R1 was provided 6 cups of water, no water was provided on October 6, 2020, 4 cups were provided on October 9 and no water was provided again until January 31, 2021. On April 16, 2021, R1 had a prescription faxed over to the facility DIrector of Nursing. Since the DIrector of Nursing was not at the facility until April 19, 2021 the prescription did not get filled and R1 did not start the prescription until April 20, 2021.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
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
04/22/2021 and conducted by Evaluator Pauline Beschorner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210422090435

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
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Terry RecordsTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure changes in resident's condition were reported to physician
INVESTIGATION FINDINGS:
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2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Pauline Beschorner conducted an unannounced complaint visit in order to deliver findings for the above complaint allegation. LPA met with Executive Director Terry Records.

The allegation alleges staff did not ensure changes in resident's condition were reported to physician. In August 2020 the faclity called R1's responsible party and asked R1 to be sent to a skilled nursing facility due to COVID-19 symptoms. R1's responsible party picked R1 up from the facility and took R1 to the hospital where R1 was not diagnosed with COVID-19 but with a UTI and bronchitis. LPA is unable to interview any witnesses and there is no documention in R1's file to cooroberate the facility did not ensure changes in resident's condition were reported to physician.

Although the above mentioned allegation may have happened or is valid, there is not a prepnderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED at this time.

Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20210422090435
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: 06/02/2021
NARRATIVE
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An exit interview was conducted and a copy of this report was reviewed and appeal rights were provided to Executive Director Terry Records whose signature on this form confirm the above mentioned documents.
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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20210422090435
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: 06/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/02/2021
Section Cited
CCR
87411(a)
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PERSONNEL REQUIREMENTS - GENERAL: Facility personnel shall at all times be...competent to provide the services necessary to meet resident needs. This requirement was not met, as evidenced by:
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The Director of Nursing and staff in memory care are no longer working at the facility. The current Director of Memory Care will implement a new ADL sheet that includes the amount of water residents are drinking daily. This sheet will be provided to LPA no later than Friday June 4, 2021.
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Based on record review and interviews the Executive Director the facility did not ensure R1 was receiving prescribed medication in a timely manner and R1 was reciving 2 liters of water daily as prescribed by physician. This poses a potential health and safety risk to residents in care.
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Type B
06/02/2021
Section Cited
CCR
87468.1(a)(2)
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PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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The Director of Nursing has implemented a procedure where staff notify the Director of Nursing if R1 refuses a shower. Since the implementation of the new policy R1 has not refused showers and has taken a shower daily.
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Based on record review and interview with Executive Director the facility only provided R1 with 5 showers in January, 3 showers in February and 1 shower in March. This psoes a potential health and safety risk to residents in care.
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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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20210422090435
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: 06/02/2021
NARRATIVE
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Executive Director Terry Records acknowledged R1 was not receiving the correct amount of fluids daily and that R1 did not start receiving medication until April 20, 2021 because the prescription did not get refilled.

The second allegation alleges staff did not meet residents hygiene needs. Based on record review R1 was only provided 1 shower in the month of March on March 11, 2021. All other showers were denied by R1. Based on interviews with the exceutive director R1 was provided 5 showers in January and 3 showers in February.

Based on LPA observations, interviews and review of records the preponderance of evidence standard has been met. Therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations Title 22, citations are being cited on the attached LIC 9099D. No civil penalties are being issued at this time.

An exit interview was conducted and Plans of Correction were reviewed and developed with the Executive Director. A copy of this report was reviewed and appeal rights were provided to Executive Director Terry Records, whose signature on this form confirm the above mentioned documents.
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
LIC9099 (FAS) - (06/04)
Page: 5 of 5