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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 03/11/2022
Date Signed: 03/11/2022 04:22:07 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
03/09/2022 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220309155434
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:
03/11/2022
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Facility faucets do not deliver hot water
INVESTIGATION FINDINGS:
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 Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to continue the investigation into the above allegations. The LPA met with Administrator, Kurt Niebres, and informed him of the purpose of the visit.
Pertaining to the allegation, "Facility faucets do not deliver hot water," it was alleged the facility did not have hot water available for resident use during personal care. On this visit the LPA toured the facility and measured the hot water temperature in eight (8) bedrooms and one (1) hall bathroom. The hot water measured within regulatory limits for each bedroom that was inspected, with the exception of bedrooms 116 (100.7 degrees Fahrenheit), 241 (103.8 degrees Fahrenheit), and 259 (98.7 degrees Fahreheit). Regulation requires that faucets used by residents for personal care attain a temperature of not less than 105 degree Fahrenheit and not more than 120 degree Fahrenheit. Therefore, based on observation, this allegation is deemed SUBSTANTIATED at this time. 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 with Niebres in which this report ws reviewed and a copy provided, along with the Appeal Rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
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-20220309155434
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: 03/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2022
Section Cited
CCR
87303(e)(2)
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MAINTENANCE & OPERATION: Water supplies & plumbing fixtures shall be maintained as follows: Faucets used by residents...shall deliver hot water. Hot water temp. controls shall be maintained to...regulate the temp. of water...to attain a temp. of not less than 105...& not more than 120 degrees F
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The Administrator stated a plumming company will be contacted to provide maintenance and proof will be sent to the Department by POC due date.
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This requirement was not met, as evidenced by: Based on observation, the Licensee did not ensure hot water temperature was regulated between 105 and 120 degrees F. Bedrooms 116, 241, and 259 did not measure within regulatory limits. This poses a potential personal rights risk to the residents in care.
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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 MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3