331880741-7-10-2023-18-AS-JDHS-CUALVD-20230801090519

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 07/10/2023
Date Signed: 07/10/2023 11:00:42 AM

Unsubstantiated

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
11/10/2021 and conducted by Evaluator Stephanie Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211110104308

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: 63	DATE:	07/10/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Adam Zenou, Manager		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff caused injuries to a resident while in care
Staff are not assisting resident with personal care

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 Manager, Adam Zenou, and informed him of the purpose of the visit.

Regarding the allegation, "Staff caused injuries to a resident while in care," it was alleged Resident One (R1) was pushed from behind by an unknown staff member, resulting in resident sustaining multiple injuries. Medical Records revealed R1 was transported to the Emergency Room on November 9, 2021. Visit information and ED Provider Notes report R1 disclosed they were physically assaulted. A Case Report revealed law enforcement was called on the scene when R1 stated they were attempting to stand up from their wheelchair, felt a push on their back which caused them to lose their balance and fall forward. Per the report, R1 did not see anyone else in the room and did not know who pushed them. ED Notes, dated November 9, 2021, show R1 sustained an abrasion to the top of left head/forehead, skin tears and bruising to right arm, bruising to left arm, abrasion to

Unsubstantiated

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20211110104308

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: 07/10/2023

NARRATIVE

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left knee, and [a] chronic sore to mid upper back. R1 was interviewed and disclosed they had sustained injuries after someone pushed them. Confidential witness interview revealed R1 has a history of exaggerating stories and making up false allegations. Staff interviews did not reveal observations of anyone entering R1's bedroom or assaulting the resident. Resident interviews did not reveal any information relating to the alleged assault. Therefore, due to insufficient evidence, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation, "Staff are not assisting resident with personal care," it was alleged, facility staff have ignored R1's request for assistance with a shower for a week. R1 was interviewed and reported they were not receiving regular showers when residing at the facility; however, no time period could be provided. Staff interviews revealed R1 did require assistance with showers, however, the resident refused staff assistance on occasion. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation occurred.

This report was reviewed with Zenou and a copy was provided.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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