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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 01/11/2024
Date Signed: 01/11/2024 02:27:18 PM


Document Has Been Signed on 01/11/2024 02:27 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: 67DATE:
01/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator, Morgan WilliamsTIME COMPLETED:
10:45 AM
NARRATIVE
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On 1/11/2024, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to address a deficiency observed during the investigation of complaint control number 18-AS-20211227094300. LPA met with Administrator, Morgan Williams, and explained the purpose of the visit.

During the complaint investigation, the facility was unable to locate Resident 1's (R1's) records for LPA's review. LPA was informed by Administrator Williams that the facility changed their management company on 7/24/2023. Administrator Williams added that R1 moved out prior to the change of management and R1’s records were not transferred to the new management team.

Pursuant to regulation 87506(e), "Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident."

Complaint control number 18-AS-20211227094300 was reported to the Department on 12/27/2021. The administrator at that time, Kurt Niebres, confirmed that R1 resided in the facility during the alleged incident time-frame. As a result, R1's records should have been available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Therefore, the facility will be issued a deficiency.

An exit interview was conducted where a copy of this report was reviewed and provided to Administrator Williams along with a Confidential Names List (LIC811), LIC809-D and Appeal Rights.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
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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Document Has Been Signed on 01/11/2024 02:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2024
Section Cited
CCR
87506(e)

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(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidenced by:
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Administrator Williams stated that the facility has conducted resident record audits for all current resident to ensure that records are available for review.
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During a complaint investigation, R1's records were unavailable for LPA's review. LPA was informed that R1's records were not transferred to the facility's new management company. This poses a potential health or safety risk to residents in care.
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Administrator Williams added that the facility has transitioned to electronic Medication Administration Records (MARs) to ensure MARs are readily available to the Department upon demand.

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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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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