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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530266
Report Date: 11/25/2025
Date Signed: 11/25/2025 01:35:37 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
11/24/2025 and conducted by Evaluator Sarina Ramirez
COMPLAINT CONTROL NUMBER: 56-AS-20251124102135
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: 135DATE:
11/25/2025
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Executive Director Cristina CeballosTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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9
Staff do not provide adequate food service
Staff speaks inappropriately to residents
INVESTIGATION FINDINGS:
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5
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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 allegations. LPAs met with Executive Director Cristina Ceballos, and discussed the purpose of the visit.

Regarding allegation #1, it is alleged the facility does not have enough snacks for residents in care. LPAs observed the facilities memory care to have enough snacks stored in their dining room kitchen.

LPAs interviewed six (6) staff, all whom agreed facility has enough snacks for residents. Based on interviews if memory care is running low on food or snacks, staff can restock from the Assisted Living kitchen. LPAs interviewed six (6) residents, all whom agreed the facility provides enough snacks, and are never denied a snack upon request.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
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 4
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
11/24/2025 and conducted by Evaluator Sarina Ramirez
COMPLAINT CONTROL NUMBER: 56-AS-20251124102135

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: 135DATE:
11/25/2025
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Executive Director Cristina CeballosTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is mismanaging residents' medication
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. LPAs met with Executive Director Cristina Ceballos, and discussed the purpose of the visit.

Regarding allegation above, LPA audited at random eight (8) residents medication, six (6) out of the eight (8) had medication administration errors.

Therefore, this allegation is found to be SUBSTANTIATED. Facility will be cited accordingly for medication error. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted with Executive Director Cristina Ceballos, and a copy of this report with appeal rights was provided at the conclusion of the visit.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 56-AS-20251124102135
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 335530266
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/03/2025
Section Cited
CCR
87465(a)(4)
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2
3
4
5
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7
87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed.
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Executive Director has agreed to train staff and submit proof of staff traininng on medication by Plan of Correction due date.
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14
Licensee/Executive Director did not ensure staff are administering medication as prescribed by physician's orders and did not complete medication log book accurately, which poses a potential risk to the health and safety of residents in care.
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9
10
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14
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7
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5
6
7
1
2
3
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5
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7
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7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20251124102135
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 335530266
VISIT DATE: 11/25/2025
NARRATIVE
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Regarding allegation #2, it is alleged staff speak inappropriately to residents. LPAs interviewed six (6) staff, all whom agreed they do not speak to residents inappropriately nor have then witnessed or heard other staff speak to residents inappropriately. LPAs interviewed six (6) residents, all whom stated they are treated and spoken very nicely by staff.

Based on LPA’s observations, staff and resident interviews, and relevant documentation, the allegations are determined to be Unsubstantiated. An Unsubstantiated finding means that although the allegation may be valid or could have occurred, there is insufficient evidence to support that the alleged violation did or did not happen.

An exit interview was conducted with Executive Director Cristina Ceballos, and a copy of this report was provided at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4