331880741-7-12-2023-18-AS-MVAO-CWYVTV-20231026164347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 07/12/2023
Date Signed: 07/12/2023 05:42:21 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
04/07/2022 and conducted by Evaluator Stephanie Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220407160211

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	KURT NIEBRES		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(951) 462-1025
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 63	DATE:	07/12/2023
		UNANNOUNCED	TIME BEGAN:	05:30 PM
MET WITH:	Tammy Chavez, Wellness Director		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Staff did not seek timely medical attention for resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegation. The LPA met with Wellness Director, Tammy Chavez, and informed her of the purpose for her visit.
Regarding the allegation, "Staff did not seek timely medical attention for resident in care", it was alleged facility staff did not contact emergency medical services for Resident One (R1) when the resident had been found on the ground on or around March 27, 2022. The investigation included staff and third party interviews, records review and records collection. A third party witness and staff interview reported R1 was discovered on the floor of their bedroom on or around March 01, 2023. Interviews reported R1 was later transported to a local hospital. Interviews did not indicate whether or not facility staff refused to contact emergency medical services. 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 the alleged violation occurred. This report was reviewed with Chavez and a copy was provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

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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