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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 04/25/2023
Date Signed: 04/25/2023 03:04:07 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
05/24/2022 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220524115257
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: 75DATE:
04/25/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Residents are not smoking in designated areas
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs), Stephanie Torres and Sara Martinez, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegation. The LPAs met with Administrator, Kurt Niebres, and informed him of the purpose of the visit.

This investigation included staff/resident interviews, records review, records collection, and a tour of premises. Regarding allegation, "Residents are not smoking in designated areas," it was alleged there are multiple residents smoking in their bedrooms. A tour of the facility was conducted on May 26 2022, multiple cigarette butts were observed lying on furniture and on the floor of Resident One (R1's) bedroom. In addition, the LPA observed loose tobacco on the floor and other areas of the same room. According to Administrator, facility staff spoke with R1 daily to direct the resident to stop smoking in their bedroom. Documentation of conversations with R1 were not available. The Administrator reported R1 would be found smoking in their bedroom daily. Therefore based on observation 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
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: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
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 4
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
05/24/2022 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220524115257

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: 75DATE:
04/25/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility washing machines are in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs), Stephanie Torres and Sara Martinez, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegations. The LPAs met with Administrator, Kurt Niebres, and informed him of the purpose of the visit.

This investigation included staff/resident interviews, records review, records collection, and a tour of premises. Regarding the allegation "Facility washing machines are in disrepair" it was alleged 2/8 washing machines were working and that out of 8 drying machines only 4 were in operating conditions. A tour of the faciity was conducted on May 26 2022; the LPA observed one washing and one drying machine to be operable on each floor of the building. Per regualtory requirments, at least one machine is required to be available for use by residents who are able and who desire to do their own personal laundry. Therefore, based on observation, this allegation is deemed UNFOUNDED. A finding that the complaint is unfounded means the allegation is false, could not have happened, and/or is without a reasonable basis. This report was reviewed with Niebres and a copy was provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20220524115257
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: 04/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2023
Section Cited
CCR
87468.1(a)(2)
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PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES:(a) Residents in all RCFEs shall have all of the following...rights:(2) To be accorded safe, healthful & comfortable accommodations...This requirement was not met as evidence by: Based on observation & interviews the lincensee did not ensure
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The Administrator stated policies will be created to address resident non compliance regarding smoking in bedrooms.
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residents were accorded safe accommodations. Cigarette butts were observed lying on furniture & on the floor of R1's room. Loose tobacco was observed on the floor & other areas of the same room. This posed a potential threat to the health & safety of 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: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20220524115257
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: 04/25/2023
NARRATIVE
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has been met. A citation will be issued.

Exit interview was conducted with administrator; this report was reviewed and copy provided, along with instructions on appeal rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4