331880741-1-26-2021-18-AS-NBRN-BXPPCX-20210128101234

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 12/19/2020
Date Signed: 01/26/2021 03:07:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-26
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/14/2020 and conducted by Evaluator Shaunte Henry

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200814144105

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	GEMMA DEOSO		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(951) 462-1025
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 64	DATE:	12/19/2020
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Jenesa McDonald, Activity Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not keep the facility clean

INVESTIGATION FINDINGS:

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On 1/26/21 Licensing Program Analyst (LPA) Shaunte Henry conducted a tele-inspection due to COVID-19 in order to deliver the finding to the above allegations. LPA Henry spoke with Activity Director Jenesa McDonald
and explained the purpose of the tele-inspection.

The investigation consisted of document review and interviews. The investigation revealed that staff regularly cleaned Resident 1 (R1)'s room. LPAs observations revealed R1's room was cleaned as scheduled and the cleanings were documented.

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, therefore the allegation is UNSUBSTANTIATED at this time.

An exit interview was conducted where the report, LIC 811 were discussed with and provided to Jenesa McDonald.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Edna Musoke	TELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2021

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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