335530266-5-21-2025-56-AS-KCLS-DKYPSX-20250828113506

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 335530266
Report Date: 05/20/2025
Date Signed: 05/21/2025 08:18:51 AM

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
05/16/2025 and conducted by Evaluator Sarina Ramirez

COMPLAINT CONTROL NUMBER: 56-AS-20250516152555

FACILITY NAME:	LAKES, THE		FACILITY NUMBER:	335530266
ADMINISTRATOR:	MATSUSHITA, LORI		FACILITY TYPE:	740
ADDRESS:	5801 SUN LAKES BLVD		TELEPHONE:	(915) 845-2220
CITY:	BANNING	STATE: CA	ZIP CODE:	92220
CAPACITY:	276	CENSUS: 121	DATE:	05/20/2025
		UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Executive Director Cristina Ceballos		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff did not provide adequate supervision resulting in residents engaging in a physical altercation and resident sustaining an injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarina Ramirez 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.

Based on interviews with staff and residents, it was determined that Resident 1(R1) sustained an injury due to a fall caused by their sandals. At the time of the incident, Staff 1 (S1) was in the dining room with Resident 2(R2) when R1 entered, shouting, which led to both R1 and R2 becoming agitated. S1 promptly redirected R1 out of the dining room. While walking backward, R1's sandal caught on the floor, causing them to fall and hit their head. S1 immediately responded, providing assistance to R1 and calling 911.

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: 05/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

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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