331880741-2-24-2022-18-AS-RSTS-CXF3CZ-20231109170847

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 02/24/2022
Date Signed: 02/24/2022 04:36:43 PM

Substantiated

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
02/15/2022 and conducted by Evaluator Stephanie Torres

COMPLAINT CONTROL NUMBER: 18-AS-20220215121707

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: 66	DATE:	02/24/2022
		UNANNOUNCED	TIME BEGAN:	07:50 AM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Staff do not keep the facility free from bug infestation

INVESTIGATION FINDINGS:

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

Pertaining to the allegation, "Staff do not keep the facility free from bed bug infestation," it was alleged Resident One (R1) reported that their bedroom had an infestation of bed bugs and although they reported it to the facility, the resident had to pay out of pocket to have their bedroom treated. Staff/resident interviews were conducted, records reviewed and copies of pertinent information were obtained. The LPA toured R1's current bedroom and did not observe any insects. R1 was interviewed and reported no company provided treatments in their bedroom. Bed bugs were observed in bedrooms 138, 246, and 247. Interviews reported there were also bed bugs in bedrooms 135, 229, 230, and 236. Interviews reported the bed bugs were discovered more than one (1) year ago and facility staff have been directed to perform the treatments to mitigate the spread of the insects. It

Substantiated

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: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

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-20220215121707

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: 02/24/2022

NARRATIVE

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was reported the treatments have not mitigated the spread of the insects. The LPA observed Resident Two (R2) to have bed bug bites on their arms. Therefore, based on observation and interviews, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted with Business Office Manager, Jenesa McDonald, in which this report was reviewed and a copy provided, along with Appeal Rights. Administrator Niebres was not available to review the report.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220215121707

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/24/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/03/2022 Section Cited CCR 87307(d)(2)	1 2 3 4 5 6 7	Personal Accommodations & Services: The following...provisions shall apply to all facilities: The premises shall be maintained in a state of good repair & shall provide a safe & healthful environment. This requirement wasn't met as evidenced by: Based on observation & interviews the Licensee didn't ensure	1 2 3 4 5 6 7	BOM stated a plan will be discussed with the Administrator to work with a pest control company to address the infestation.
	8 9 10 11 12 13 14	a safe & healthful environment was provided. Bed bugs were observed in several rooms. Interviews reported staff have been directed to do treatments to mitigate the spread, however, it continues. R1 & R2 were observed to have bed bug bites. This poses a potential threat to the health & safety of the residents in care.	8 9 10 11 12 13 14
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC9099 (FAS) - (06/04)

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