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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 01/31/2024
Date Signed: 01/31/2024 04:19:53 PM


Document Has Been Signed on 01/31/2024 04:19 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: 68DATE:
01/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Administrator, Morgan WilliamsTIME COMPLETED:
04:35 PM
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Licensing Program Analysts (LPAs) Janira Arreola and Kathleen Banarasvong conducted a required annual visit. LPA was greeted and was granted entry and met with Administrator, Morgan Williams, who was informed of the purpose of the visit.

The facility is a two story home dining area, kitchen, resident rooms, bathrooms, and activity room. LPA were provided with fire exits and plan on renovations. The facility does not have a pool or fire arms. The facility is designated as a residential care facility for the elderly serving residents ages 60 and above. LPAs observed the following:

LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPAs checked the staff roster and found sufficient coverage during the time of the visit. LPA verified CPR certification for staff on shift. Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards and contained outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The cleaners and medications were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 105F.

No deficiencies were cited at the time of the visit. Due to time constraints, the administrator was informed that the annual will require a continuation on a later date. An exit interview was conducted where a copy of this report was provided to Administrator, Morgan Williams.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
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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