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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 09/22/2023
Date Signed: 09/22/2023 02:02:04 PM


Document Has Been Signed on 09/22/2023 02:02 PM - 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:BERCOVICH, MOISES UFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 67DATE:
09/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Morgan Williams, AdministratorTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to address violations observed during the investigation of complaint #18-AS-20230915084347. The LPA met with Administrator, Morgan Williams, and informed her of the purpose for her visit.

During the complaint investigation, the facility was unable to provide the LPA with the staff file for S1. S1 no longer works for the facility. Administrator Williams stated she was unsure if a file was created for S1 by the previous management company. This violation poses a potential threat to the health, safety, and personal rights of the resident in care. A citation will be issued.

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.











NOTE: The Licensee incorporated a new management company into the LLC to oversee operation of the facility. The new management company has been operating the facility since July 01, 2023.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
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 09/22/2023 02:02 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: 09/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2023
Section Cited
CCR
87412(a)

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PERSONNEL RECORDS: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee...This requirement was not met, as evidenced by: Based on record review, the Licensee did not ensure a file was
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The Administrator stated current staff files will be audited and verified to contain all documentation required by POC due date.
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maintained for S1. The facility was unable to provide the LPA with the staff file for S1. Administrator Williams stated she was unsure if a file was created for S1 by the previous management company.
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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: Rikesha StampsTELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
LIC809 (FAS) - (06/04)
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