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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 08/17/2023
Date Signed: 08/17/2023 03:32:30 PM

Unsubstantiated


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
08/10/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230810161822
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: 61DATE:
08/17/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Morgan WilliamsTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility staff are illegally evicting resident from the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation in regards to the allegation noted above. LPA met with Morgan Williams, Administrator. LPA explained the purpose of the visit and the elements of the allegation. The allegation was investigated, the investigation consisted of observation, interviews and a review of records.

Regarding facility staff are illegally evicting a resident from the facility. On or around August 5, 2023 Resident #1 (R1) was exhibiting behaviors where they were a danger to themself and others as a result law enforcement was contacted and R1 was placed on a 51/50 hold. It was reported that R1 was ready to be discharged on August 8, 2023 and that the Administrator stated R1 needed to be reassessed for appropriate placement. R1 was reassessed by the Wellness Director and Director of Business Development and was found to still be exhibiting behaviors, and was not suitable to return to the facility. After an additional two days R1 was medically cleared for discharge. R1 returned back to the facility on August 10, 2023. Based on observation, interviews and record review the allegation of facility staff are illegally evicting resident from the
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
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 2
Control Number 18-AS-20230810161822
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: 08/17/2023
NARRATIVE
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facility is UNSUBSTANTIATED. An UNSUBSTANTIATED finding means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.

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

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2