331880741-6-22-2023-18-AS-JESL-CTAVTD-20230630164259

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 06/22/2023
Date Signed: 06/22/2023 10:05:23 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE 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
12/28/2021 and conducted by Evaluator Stephanie Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211228101241

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: 74	DATE:	06/22/2023
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility staff are not meeting resident's hygiene needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegations. The LPA met with Administrator, Kurt Niebres, and informed him of the purpose of her visit.

Regarding the allegation, "Facility staff are not meeting resident's hygiene needs," it was alleged that on December 28, 2021, R1 was having difficulty contacting staff in order to assist with getting cleaned up after a period of incontinence. Administrator Niebres was interviewed and did not have any knowledge regarding the allegation. R1 was interviewed and reported to have requested showers from staff and being told they cannot help because there were not enough staff to assist with transferring them out of bed. A Situational Awareness and Response Assistant (SARA) log was obtained for December 28, 2021. The report revealed the call system was activated at 9:34 AM and completed at 9:39 AM. Staff interviews could not corroborate or refute the alleged violation took place. The LPA obtained a shower log revealing R1 did not receive showers from staff from December 19, 2021 to December 30, 2021. In addition, the facility's Plan of Operation indicates

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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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Control Number 18-AS-20211228101241

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ARLINGTON RIVERSIDE SENIOR COMMUNITY	FACILITY NUMBER: 331880741
	VISIT DATE: 06/22/2023

NARRATIVE

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residents will receive assistance with showers at least two times per week. Therefore, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted; this report was reviewed with Niebres and a copy was provided, along with instructions on appeal rights.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20211228101241

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ARLINGTON RIVERSIDE SENIOR COMMUNITY	FACILITY NUMBER: 331880741
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/26/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to Section 87468.1...residents in privately operated RCFEs shall have all of the following...rights: (4) To care, supervision, & services that meet their individual needs & are delivered by staff that are sufficient in numbers,	1 2 3 4 5 6 7	The Administrator stated he will put procedures in place to ensure shower logs are reviewed regularly. He stated he will provide a copy of the procedures to the LPA by the POC date.
	8 9 10 11 12 13 14	qualifications, & competency to meet their needs. This requirement was not met, as evidenced by: Based on interviews and records, the Licensee did not ensure R1 received services from staff to be cleaned up after a period of incontinence.	8 9 10 11 12 13 14
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

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