<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530266
Report Date: 12/06/2024
Date Signed: 12/06/2024 11:11:03 AM

Document Has Been Signed on 12/06/2024 11:11 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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: 99DATE:
12/06/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee Shlomo Aron TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sarina Ramirez conducted an announced visit to the facility for the purpose of a Change of Ownership evaluation. LPA met with Licensee Shlomo Aron. An initial application for change of ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Centralized Applications Bureau (CAB) on 06/26/2024 for a total capacity of two hundred and seventy-six (276) residents. Fire clearance was granted on 08/16/2024. LPA observed the following:

Eight (8) bedrooms and Nine (9) bathrooms. There is a gated pool inaccessible to residents in care. The physical plant, in general, was in good repair. Buildings and grounds are free from hazards. Indoor and outdoor passageways were free of obstruction. There is a locked area for medications, cleaning supplies, and sharps. LPA observed a working telephone and basic laundry equipment. Resident bedrooms had the required bedding and furniture. Bedrooms had sufficient lighting. LPA measured the hot water temperature in the resident bathrooms, and it ranged from 105 to 114 degrees F. The facility had a sufficient amount of linen and hygiene items for the residents. The facility had a sufficient amount of nonperishable and perishable food items. The food was kept in a safe and healthful manner. The facility menu was available for review. Dishes, glasses, and utensils were in good condition. The facility had a designated area for staff and client records. Facility sketch, personal rights, CCLD complaint poster, Ombudsman poster, and schedule of activities were posted in a common area. The facility was equipped with a complete first aid kit and manual. There is adequate seating in the common areas. Facility had a supply of activities for the residents.

Pre-licensing inspection is complete, and no corrections are needed to be made. Facility appears to be ready for licensure. An exit interview was conducted where this report was discussed and provided to the Licensee Shlomo Aron.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1