<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 07/20/2023
Date Signed: 07/20/2023 05:16:23 PM

Substantiated


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
07/17/2023 and conducted by Evaluator Stephanie Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230717104706
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: 67DATE:
07/20/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Moises Bercovich, AdministratorTIME COMPLETED:
05:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Residents were moved out of the facility without their consent
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Moises Bercovich, the current Administrator as of July 01, 2023, and informed him of the purpose for her visit.

A report was received by the Department alleging four (4) residents were removed from the facility without their consent in June 2023. The investigation included interviews with staff, residents, and witnesses; records review and records collections. Two resident interviews reported they were removed from Arlington Riverside Senior Community and taken to another facility in Riverside County in or around June 2023. The residents reported they were not provided notice of being moved or asked for consent to be removed from the facility. The Licensee, Kevin Long Ha, was interviewed and denied the allegation, stating the residents were issued eviction notices and later agreed to move out of the facility on their own. Proof of eviction notices were not observed on file nor could any evidence be obtained to show the residents moved out of the facility on their own. Therefore,
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
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-20230717104706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 COMMUNITY
FACILITY NUMBER: 331880741
VISIT DATE: 07/20/2023
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
based on interviews, this allegation is deemed 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 Bercovich; this report was reviewed and a copy, along with instructions on appeal rights, was provided
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20230717104706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 COMMUNITY
FACILITY NUMBER: 331880741
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2023
Section Cited
CCR
87468.2(a)(20)
1
2
3
4
5
6
7
Additional Personal Rights of Residents in Privately Operated Facilities: In addition to Section 87468.1...residents in privately operated RCFE shall have all of the following personal rights: To be protected from involuntary transfers, discharges, & evictions. A licensee shall not involuntarily transfer
1
2
3
4
5
6
7
The Administrator stated he would make efforts to bring the residents who were improperly removed from the facility back if agreed upon and are appropriate for placement.
8
9
10
11
12
13
14
or evict residents for reasons other than those permitted by state law or regulations & shall comply with all eviction & relocation protections for residents...This requirement was not met, as evidenced by: Based on interviews the Licensee did not ensure residents were protected from an involuntary transfer.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3