<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 03/23/2021
Date Signed: 03/23/2021 01:08:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:GEMMA DEOSOFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 57DATE:
03/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Gemma Deoso, AdministratorTIME COMPLETED:
01:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to deliver the findings of the investigation on complaint #18-AS-20210129151201. During the course of the investigation a violation, relating to record keeping, was observed.

The January 2021 Medication Administration Record (MAR) for Resident One (R1) was incomplete; the first page could not be found by Administrator, Gemma Deoso, and thus could not be provided to the LPA. Per Deoso, it is the facility's policy to maintain a MAR for all medications poured and/or passed by community staff. R1 is currently a resident of the facility.

The facility was documenting medication administration on Progress Notes, however, not all of R1's medications were documented as being dispensed. This posed a potential health and safety risk to the resident in care.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 03/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/06/2021
Section Cited

1
2
3
4
5
6
7
Resident Records: Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidenced by: Based on records review the licensee did not ensure records were kept on file for a minimum of 3 years.
8
9
10
11
12
13
14
R1's MAR was incomplete and unavailable for Department review. This poses a potential health and safety risk to the resident in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
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.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2