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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 07/10/2023
Date Signed: 07/10/2023 10:55:50 AM


Document Has Been Signed on 07/10/2023 10:55 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:KURT NIEBRESFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 63DATE:
07/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Adam Zenou, ManagerTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to address a violation observed during the investigation of complaint #18-AS-20211110104308. The LPA met with Manager, Adam Zenou, and informed him of the purpose for her visit.

During the complaint investigation it was revealed Resident One (R1) was hospitalized on November 09, 2021. A record review revealed no incident report was on file for the hospitalization. This posed a potential threat to the health, safety and personal rights of the residents in care. Therefore, a citation will be issued.

An exit interview was conducted; this report was reviewed with Zenou and a copy was provided, along with instructions on appeal rights.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/10/2023 10:55 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2023
Section Cited
CCR
87211(a)(1)(D)

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REPORTING REQUIREMENTS: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following: (1) A written report shall be submitted to the licensing agency & to the person responsible for the resident within 7 days of the occurrence of any of the events
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The manager reported a statement of understanding of the reporting requirements will be submitted to the Department by POC due date.
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specified in (A) - (D) below. (D) Any incident which threatens the welfare, safety or health of any resident... During the complaint investigation it was revealed R1 was hospitalized on 11/09/21. A record review revealed no incident report was on file for the hospitalization.
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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 HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
LIC809 (FAS) - (06/04)
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