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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 07/24/2023
Date Signed: 08/22/2023 07:48:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/05/2020 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200605092543
FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:HIGGINS, DEBORAHFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 66DATE:
07/24/2023
UNANNOUNCEDTIME BEGAN:
05:20 PM
MET WITH:Crystal Maldonado, Buisness Office ManagerTIME COMPLETED:
06:45 PM
ALLEGATION(S):
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Staff neglect resulted in resident #1 (R1) sustaining an unstageable pressure injury (ulcer).
INVESTIGATION FINDINGS:
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* This is an ammended report.
This unannounced visit conducted by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegation mentioned above. The Department completed investigation of staff neglect that led to Resident 1 (R1) sustaining unstageable pressure injury while in care. The investigation included inspection of facility, interviews with staff and witness’, and review of facility and hospice records. Based on the investigation, there is preponderance of evidence to support that facility staff neglected R1. Investigation revealed the following information: R1 was a resident of the facility from March 15, 2020 through May 29, 2020. According to hospice records, dated March 16, 2020, and April 30, 2020, R1 did not have any pressure injuries identified. These hospice records were made available to staff during hospice care.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 18-AS-20200605092543
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 07/24/2023
NARRATIVE
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Investigation revealed that from May 5, 2020, through May 7, 2020, hospice agency staff attempted to contact facility staff for a tele-health visit. However, hospice agency staff were unsuccessful in making contact via telephone. Specifically, it was found that that on May 5, 2020, a Hospice LVN attempted numerous calls to facility staff for a tele-health visit and all calls were unsuccessful. After the hospice staff were not able to get in touch with anyone from the facility after several calls, an in-person hospice visit was conducted on May 7, 2020. At the time of this visit, R1 was observed to have a stage II pressure injury to the coccyx. Hospice Plan of Care (POC) dated May 7, 2020, instructed facility to “assess alteration in skin integrity every visit; assess changes in wound status for size, integrity, location, type/stage, signs and symptoms of infection, drainage, and effectiveness of current treatment.”. May 8, 2020 through May 13, 2020 the hospice agency did not hear from the facility regarding R1. On May 13, 2020, R1s hospice agency received a call from facility LVN (S3) informing them that R1’s wound “looked bad.” Hospice staff went to the facility on May 13, 2020. According to hospice records, the pressure injury to the coccyx was now identified as unstageable. POC was put in place by hospice agency. Facility staff were also provided with instructions regarding treatment for R1 pressure injury. It was revealed that (S2) was at least one of the staff who had knowledge of the care to be provided to R1. However, investigation further revealed that facility records do not support that staff provided the care to R1 as required. Specifically, facility staff were instructed to reposition R1 every two-three hours and to change dressing every three days or as necessary.

When interviewed, former administrator (S1) admitted to knowing about the pressure injury. However, investigation found that (S1), along with facility staff, failed to ensure that R1 was free from neglect which resulted in R1 sustaining an unstageable pressure injury. As a result, the department has substantiated the complaint allegation as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with and furnished to the facility representative. Please see LIC 9099D. The licensee has been informed that an enhanced civil penalty may be assessed based on Health and Safety Code 1569.49 after further review by the department.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20200605092543
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2023
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities: ...Residents in privately operated RCFEs shall have all of the following...rights: To care, supervision, & services that meet
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The facility has employed a third party consultant to further train employees in areas care and supervision, medication. Plan will be to provide logs for care of residents on Hospice regarding care provided, such as
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their individual needs and are delivered by staff that are sufficient in numbers, qualifications, & competency to meet their needs. This requirement was not met as evidenced by: Based on interviews & records review, it was found that the Licensee did not ensure R1 received the care, supervision & services to meet R1’S needs as evidenced in R1 developing an unstageable pressure injury. This posed an immediate risk to R1.
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 incontinent care and repositioning. Copy of log to be provided to CCL by POC due date.


*A Civil Penalty assessment accompanies this deficiency.
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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: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
LIC9099 (FAS) - (06/04)
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