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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530266
Report Date: 04/24/2025
Date Signed: 04/24/2025 02:31:00 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
04/21/2025 and conducted by Evaluator Sarina Ramirez
COMPLAINT CONTROL NUMBER: 56-AS-20250421152622
FACILITY NAME:LAKES, THEFACILITY NUMBER:
335530266
ADMINISTRATOR:MATSUSHITA, LORIFACILITY TYPE:
740
ADDRESS:5801 SUN LAKES BLVDTELEPHONE:
(915) 845-2220
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:276CENSUS: 113DATE:
04/24/2025
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Executive Director Cristina CeballosTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained unexplained bruising.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Sarina Ramirez and Eldin Serrano conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegation. LPA met with Executive Director Cristina Ceballos, and discussed the purpose of the visit.

Interviews conducted with staff, residents, and outside parties revealed that around 4/18/25, Resident 1 (R1) sustained unexplained bruising. After an internal investigation, and interviews with staff; staff suspect Resident 2 (R2) attempted to remove R1’s doll and may have caused the unexplained bruising. Due to both residents being in memory care there is not enough evidence to prove how R1 sustained the unexplained bruising.

Based on observation, interviews, and pertinent documents the allegation is unsubstantiated. An Unsubstantiated complaint means, that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
An exit interview was conducted with Executive Director Cristina Ceballos and a copy of this report was provided at the conclusion of the visit.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
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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