331880741-7-10-2023-18-AS-RSTS-CZZS9D-20240131124035

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 07/10/2023
Date Signed: 07/10/2023 03:29:17 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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 Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220309153138

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	KURT NIEBRES		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(951) 462-1025
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 63	DATE:	07/10/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Crystal Maldonado, Business Office Manager		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident hospitalized due to improper care of catheter.
Resident is malnourished.
Resident is dirty.
Feces observed on carpet.
Facility has an odor.
Facility staff are unable to communicate with resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegations. The LPA met with Crystal Maldonado, Business Office Manager, and informed him of the purpose for her visit.

A report was received alleging Resident One (R1) was hospitalized due improper care of their catheter by facility staff. R1's responsible party could not identify which hospital R1 was transferred to. When requests for records were sent out to medical centers in the area, there was no record of the resident being in care. R1's Physician's Report for Residential Care Facilities for the Elderly (RCFE), dated January 31, 2022, revealed the resident did not have the capacity to care for their own toileting needs. Administrator Niebres was interviewed; he reported R1 did need assistance with toileting which was being provided by staff. Staff interviews were inconsistent; one staff reported the resident could care for their own toileting needs, while another staff reported R1 needed assistance. A statement could not be obtained from R1, due to the resident passing away in September 2022. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220309153138

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 07/10/2023

NARRATIVE

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this time.

It was also reported R1 appeared to be malnourished while in care. A third-party witness reported R1's face was observed to be skinny, darkened eyes, and their lips were cracked. The witness also reported R1 required assistance with meals due to limitations with use of their arms. R1's Physician's Report for Residential Care Facilities for the Elderly (RCFE), conducted on January 31, 2022, revealed the resident did not have the capacity to eat independently. Administrator Niebres was interviewed; he reported R1 did not need assistance with meals. Staff interviews were inconsistent; one staff reported the resident could care for their own feeding, while another staff reported R1 needed assistance. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

Another report was obtained by the Department alleging R1 was observed, on or around February 24, 2022 with urine on their pants, no adult brief, had a bad odor, and had feces on their sandal and sock. Staff interviews were inconsistent; one staff reported the resident could care for their own Activities of Daily Living (ADLs), while other staff reported R1 needed assistance. One staff interview reported R1 would refuse care from certain staff if they did not speak their preferred language. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

A fourth report was received by the Department alleging feces was observed on the floor of R1’s bedroom on multiple occasions in February and March 2022. A third party witness reported R1 does utilize adult briefs. One staff interview reported feces was observed on the ground of R1's bedroom on one occasion. Details of the observation could not be provided. Due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

In addition, it was reported R1's bedroom had an ammonia odor while the resident was in care. Staff interviews could not provide any information on whether R1's bedroom had been observed to have an odor or not. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

It was also reported facility staff were unable to communicate with R1 while they were in care causing the resident to be fearful. Staff interviews reported R1 spoke limited English. Staff and third-party interviews reported there was at least one care staff member on shift, who spoke the same language as the resident and would assist with translation. Due to insufficient information, this allegation is deemed UNSUBSTANTIATED

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220309153138

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 07/10/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	at this time. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations occurred. An exit interview was conducted and a copy of the report, along with LIC 811, was provided to Maldonado.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

LIC9099 (FAS) - (06/04)

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