331880741-9-8-2023-18-AS-RSTS-CVWSGQ-20230922135216

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 09/08/2023
Date Signed: 09/08/2023 05:11:58 PM

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
09/05/2023 and conducted by Evaluator Stephanie Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230905090529

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	BERCOVICH, MOISES U		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(951) 462-1025
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 64	DATE:	09/08/2023
		UNANNOUNCED	TIME BEGAN:	08:49 AM
MET WITH:	Morgan Williams, Administrator		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff do not keep the facility free from rodents.
Staff refuse to assist a resident to shower

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegations. The LPA met with Administrator, Morgan Williams, and informed her of the purpose for her visit.

The investigation included staff and resident interviews, review of records, and receipt of relevant documentation.

A report was received by the Department alleging a rodent bit Resident One's (R1's) hand on or around September 05, 2023, which caused an injury. R1 was interviewed and stated they were not bit, rather, they were scratched by a rat on or around August 31, 2023. The resident later changed their statement and stated the rodent was a mouse and the incident occurred on September 05, 2023. The LPA observed R1's left hand to have a light bruise and a red line. The LPA did not observe the skin to be broken. Two additional resident interviews revealed a rodent was observed on or around August 06, 2023. Residents reported the rodent

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

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-20230905090529

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: 09/08/2023

NARRATIVE

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was caught and removed from the facility within two (2) days. Administrator Williams reported, and email correspondence confirmed, a pest control company was contacted by the facility. Williams reported the company made a visit on or around September 06, 2023, in which they put measures in place that eventually lead to the removal of one (1) rodent near R1's bedroom. No information was received to indicate the facility did not take quick measures to eliminate the presence of the rodent. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

In addition, a report was received by the Department alleging facility staff refused to assist R1 with a shower on 09/07/2023. R1 was interviewed and reported staff have refused to assist them with showering since they were admitted to the facility (June 05, 2023). It was reported staff have refused to assist R1 with washing their private area and the area underneath their stomach (areas the resident is unable to wash). Staff interviews revealed R1 can wash their own body and requires minimal to no assistance, such as standing nearby to ensure the resident does not fall. A Physician's Report for Residential Care Facilities for the Elderly (RCFE) revealed R1 does need minimal assistance, though a description of the assistance was not identified in the report. R1's Admission Agreement was reviewed to identify what services were agreed to be provided to the resident. The document revealed no assistance with bathing was agreed to be provided. 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 that the alleged violations occurred.

An exit interview was conducted, this report was reviewed with Administrator Williams and a copy was provided.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC9099 (FAS) - (06/04)

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