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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530266
Report Date: 11/18/2024
Date Signed: 11/18/2024 10:49:04 AM

Document Has Been Signed on 11/18/2024 10:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 9-14-8201
, CA 95814
FACILITY NAME:LAKES, THEFACILITY NUMBER:
335530266
ADMINISTRATOR/
DIRECTOR:		MATSUSHITA, LORIFACILITY TYPE:
740
ADDRESS:5801 SUN LAKES BLVDTELEPHONE:
(915) 845-2220
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY: 276CENSUS: DATE:
11/18/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Lori Matsushita & Steven AronTIME VISIT/
INSPECTION COMPLETED:
10:40 AM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 276
Census (if any clients in care): 100
COMP II Participants: Lori Matsushita (A), Steven Aron (C)
Interview Method: Telephone interview

On November 18, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.
During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:

1. Facility operation: License type, client/resident populations, and program

2. Activities, Transportation

3. Staffing requirements, Transportation

4. Unusual Incidents/Timeline to report

5. General provisions / pre licensing readiness

SUPERVISORS NAME: Jude De La Concepcion
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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