331880741-4-22-2022-18-AS-RSTS-CZYV6N-20240130150946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 04/22/2022
Date Signed: 04/22/2022 06:10:10 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
01/11/2021 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210111100922

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: 64	DATE:	04/22/2022
		UNANNOUNCED	TIME BEGAN:	03:50 PM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	06:10 PM

ALLEGATION(S):

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Resident's pull cord is not answered in a timely manner

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 into the above allegation. The LPA met with Administrator, Kurt Niebres, and informed him of the purpose of her visit.

Pertaining to the allegation, "Resident's pull cord is not answered in a timely manner," it was alleged that on January 10, 2021 the facility staff failed to assist Resident One (R1) to the restroom after a call was made utilizing the signal system. One (1) of six (6) resident interviews revealed the facility staff were not answering requests for assistance made on the signal system during this time period. This resident reported the call was being made in order to receive assistance with toileting. It was reported the toileting needs are not being met by the facility staff. A Situational Awareness and Response Assistant (SARA) log was obtained and reviewed for January 10, 2021. Multiple calls were shown to have lasted for at least thirty minutes. Staff interviews revealed the facility policy is for staff to answer calls made on the signal system in under fifteen (15) minutes.

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: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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-20210111100922

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: 04/22/2022

NARRATIVE

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This poses a potential threat to the health, safety, and personal rights of the residents in care. Therefore, based on interview and records review, 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 and civil penalty will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted with staff, Donna Ray; this report was reviewed and a copy was provided, along with LIC 421IM and Appeal Rights.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20210111100922

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: 04/22/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/29/2022 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, & competent to provide the services necessary to meet resident needs...This requirement wasn't met, as evidenced by: Based on records & interviews, the Licensee didn't ensure personnel were	1 2 3 4 5 6 7	The LPA requested the facility put a plan in place detailing how facility management will ensure the calls from the signal system are met in a sufficient amount of time.
	8 9 10 11 12 13 14	sufficient in numbers to meet needs. Interview revealed staff were not answering requests for assistance. It was reported that toileting needs are not being met by staff. A SARA log revealed multiple calls lasted for at least 30 mins.	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: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC9099 (FAS) - (06/04)

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