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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 11/09/2023
Date Signed: 11/09/2023 04:27:20 PM


Document Has Been Signed on 11/09/2023 04:27 PM - 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: 73DATE:
11/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Morgan Williams, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to verify non-ambulatory residents were moved to the first floor following a fire clearance violation observed during a visit on 10/06/2023. The LPA met with Administrator, Morgan Williams, and informed her of the purpose of the visit.

The LPA reviewed resident records and the facility resident roster. After further documentation was received, no non-ambulatory residents were found to be residing on the second floor. No health and safety concerns were observed at time of visit.

This report was reviewed with Administrator Morgan 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: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
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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