331880741-3-23-2021-18-AS-NBRN-C2KV66-20210430160902

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 03/23/2021
Date Signed: 03/23/2021 01:07:04 PM

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
01/29/2021 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210129151201

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	GEMMA DEOSO		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(951) 462-1025
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 57	DATE:	03/23/2021
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Gemma Deoso, Administrator		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff is not properly administering a resident's medication while in care

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 on the above allegation. The LPA was greeted and granted entrance into the building. The LPA met with Administrator, Gemma Deoso.

Regarding the allegation, "Staff is not properly administering a resident's medication while in care," it was alleged Resident One's (R1's) medications were being mismanaging by facility staff during the month of January 2021. On February 04, 2021 the LPA initiated the investigation; the LPA reviewed records and obtained copies of pertinent information. A medication audit was conducted on March 08, 2021; six (6) of R1's medications, refilled on January 18, 2021, were observed to still be in the facility's possession and being dispensed to R1. Per Administrator Deoso, the facility receives extra medication from R1's pharmacy, resulting in the excess of medications on hand. According to third party interviews and medication labels, R1's pharmacy does not dispense more than thirty (30) days supply of those six (6) medications to the facility. Interviews also reported medications from January 18, 2021 should have finished prior to the new refill on February 15, 2021.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20210129151201

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: 03/23/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/26/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on a medication audit, the Licensee did not ensure personnel were competent to	1 2 3 4 5 6 7	The Administrator stated in-service training will be provided to all staff who assist with medication administration. Training will address how to follow medication labels.
	8 9 10 11 12 13 14	provide the services necessary to meet R1's needs. Six of R1's medications, refilled on 01/18/21, were observed to still be in the faciilty's possession and being dispensed to R1. Interviews reported medications from 01/18/21 should have finished prior to the new refill on 02/15/21.	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: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20210129151201

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: 03/23/2021

NARRATIVE

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No record of R1's absences or refusals to accept the medications were found on file. This posed an immediate health and safety risk to the resident in care. Therefore, 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. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted with Administrator Deoso in which this report was reviewed and a copy provided, along with LIC 9099D, LIC 811, and Appeal Rights.

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021

LIC9099 (FAS) - (06/04)

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