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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 04/28/2022
Date Signed: 04/28/2022 12:57:40 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 COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:KURT NIEBRESFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 64DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
12:56 PM
ALLEGATION(S):
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Staff did not properly assist resident with their oxygen administration
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegations. The LPA met with Administrator, Kurt Niebres, and informed him of the purpose of her visit.

Pertaining to the allegation, "Staff did not properly assist resident with their oxygen administration," it was alleged, that around March 27, 2022 and April 02, 2022, staff could not find the oxygen machine for R1 and, as a result, the resident went without oxygen administration for one day. Interviews were conducted with staff, resident and third parties. According to Administrator Niebres, R1 was discharged from their hospice agency following the resident's hospitalization on March 01, 2022. Interviews revealed that, as a result of the discharge, R1's equipment, including the oxygen concentrator, was retrieved by the company on March 09, 2022. R1 returned to the facility, from a skilled nursing facility, on April 04, 2022, with a limited supply of oxygen. According to Niebres, a spare concentrator was provided on April 05, 2022. A records review was conducted; an Order Listing Report, dated December 08, 2021, revealed R1 had an order for oxygen use and
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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 2
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: 04/28/2022
NARRATIVE
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the directives were, "as needed". Interview revealed R1 requested the oxygen and sustained a head ache as a result of not receiving it until the following day. Therefore, based on interviews, 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 violations occurred.

An exit interview was conducted; this report was reviewed with Niebres and a copy was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2