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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 10/10/2023
Date Signed: 10/23/2023 08:37:59 AM


Document Has Been Signed on 10/23/2023 08:37 AM - 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:WILLIAMS, MORGAN EFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 69DATE:
10/10/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kevin Long Ha, LicenseeTIME COMPLETED:
01:30 PM
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Regional Manager, Reyna Lacey, Licensing Program Manager, Rikesha Stamps, and Licensing Program Analyst, Stephanie Martinez, conducted a virtual office meeting with Licensee, Kevin Long Ha. The purpose for the meeting was to discuss the findings of a solvency audit report dated 03/15/2023.

The audit findings report was reviewed with the Licensee. The audit found the licensee does not generate sufficient income to meet operating costs. Additional information was provided by the Licensee regarding unpaid balances for the facility. Corroborating records will be provided to the Department via financial monitoring. Financial records (bank statements, utility bills, mortgage payment and food receipts) for the months of May through July 2023 were requested and are due by 10/20/2023. Financial records for the months of August through October 2023, for the next quarter review period, are due by 11/30/2023. The Regional Office requested a copy of the facility's current proof of liability insurance which is due by 10/17/2023.

The Licensee was notified the facility would be placed on financial monitoring for up to twelve (12) months.

This report was reviewed with Licensee Ha and a copy was provided.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
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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