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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 08/09/2023
Date Signed: 08/10/2023 05:18:13 PM


Document Has Been Signed on 08/10/2023 05:18 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/10/2023 05:08 PM

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

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-20220509092255. The LPA met with Morgan Williams, Manager, who was brought on by the new management company on August 01, 2023. The LPA informed her of the purpose for her visit.

During the investigation of complaint #18-AS-20220509092255, the LPA observed, on May 11, 2022, a blank Admission Agreement on file for Resident One (R1). The resident had been residing in the facility since October 2021. This violation poses a potential threat to the personal rights of the resident in care. A citation will be issued, in addition to a civil penalty, due to this violation being issued in the past.

An exit interview was conducted; this report was reviewed with Williams and a copy was provided, along with LIC 811 and instructions on appeal rights.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
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 08/09/2023 03:03 PM - 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: 08/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2023
Section Cited
CCR
87507(c)

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ADMISSION AGREEMENTS: (c) Admission agreements shall be signed & dated...by the resident or the resident’s representative...& the licensee or the licensee’s designated representative no later than 7 days following admission. This requirement was not met, as evidenced by:
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The new manager reported an Admission Agreement will be filed for R1 and a copy will be submitted to the LPA by POC due date.
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Based on record review, the Licensee did not ensure an Admission Agreement was completed for R1. The LPA observed, on 05/11/22, a blank Admission Agreement on file for R1. The resident had been residing in the facility since October 2021.
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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: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
LIC809 (FAS) - (06/04)
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