331880741-4-15-2022-18-AS-MVAO-CWYVTX-20231026164349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 04/15/2022
Date Signed: 04/15/2022 03:44:02 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
04/07/2022 and conducted by Evaluator Stephanie Torres

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: 64	DATE:	04/15/2022
		UNANNOUNCED	TIME BEGAN:	08:14 AM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff yelled at resident in care
Staff handled resident in a rough manner
Facility overcharged resident in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to continue the investigation into the above allegations. The LPA met with Administrator, Kurt Niebres, and informed him of the purpose of her visit.

Regarding the allegation, "Staff yelled at resident in care," it was alleged an unknown staff yells at R1 when assisting them up from the floor. Administrator Niebres was interviewed and reported no knowledge of any staff members yelling at R1. Staff/Resident interviews were conducted; interviews could not corroborate or refute the alleged violation took place. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation, "Staff handled resident in a rough manner," it was alleged an unknown staff member, when providing assistance to R1 to get up off the floor, quickly picks the resident up and threw them onto their bed. Administrator Niebres was interviewed and reported no knowledge of any staff members yelling

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022

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 3

Control Number 18-AS-20220407160211

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: 04/15/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

at R1. Staff/Resident interviews were conducted; interviews could not corroborate or refute the alleged violation took place. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation, "Facility overcharged resident in care," it was alleged the facility is charging R1 rent for four (4) months which were previously paid to the facility. Staff and resident interviews were conducted. Administrator Niebres denied the allegation. He reported R1 pays $1,000 in rent and only owes payments for March and April of the year 2022. Niebres reported the resident has a balance of $2,000. R1 was interviewed and could not provide any information on the allegation. Therefore, based on interviews, this allegation is deemed UNSUBSTANTIATED at this time.

A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations occurred.

This report was reviewed with Niebres and a copy was provided.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3