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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 03/30/2021
Date Signed: 04/01/2021 08:54:13 AM



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
03/01/2021 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210301135754
FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:GEMMA DEOSOFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 57DATE:
03/30/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Gemma Deoso, AdministratorTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Resident's medication is not being dispensed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to the facility to deliver the findings of the investigation on the above allegation. The LPA met with Administrator, Gemma Deoso, who was informed of the purpose of the visit.

Regarding the allegation, "Resident's medication is not being dispensed," it was alleged two (2) of Resident One's (R1's) medications were not properly dispensed on or around February 20, 2021. The LPA initiated the investigation on March 05, 2021; the LPA reviewed records, medication, and took copies of pertinent information. Third party interviews conducted revealed R1's medications were delivered to the facility on February 19, 2021 and staff should have commenced the cycle on February 24, 2021. A medication review revealed the two (2) medications identified did have additional pills in their respective packages than scheduled to have. With R1's recent hospitalization accounted for; additional pills were still identified in the medication packaging. This posed an immediate risk to the resident in care. This allegation is deemed SUBSTANTIATED
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021
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 7
Control Number 18-AS-20210301135754
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: 03/30/2021
NARRATIVE
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based on interviews and observation. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted with Deoso, in which this report was reviewed, and a copy provided, along with LIC 9099D, LIC 811 and Appeal Rights.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
03/01/2021 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210301135754

FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:GEMMA DEOSOFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 57DATE:
03/30/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Gemma Deoso, AdministratorTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Facility failed to report resident fall to responsible party.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to the facility to deliver the findings of the investigation on the above allegation. The LPA met with Administrator, Gemma Deoso, who was informed of the purpose of the visit.

Pertaining to the allegation, "Facility failed to report resident fall to responsible party, " it was alleged facility staff did not notify R1’s responsible party of the resident’s fall, at the facility, on February 26, 2021. It was confirmed R1 did sustain a fall at the facility, which resulted in a hospitalization on February 26, 2021. Administrator, Deoso, reported R1 is self responsible and, therefore, no additional emergency contact would have been made for the resident. A records review was conducted and an Identification and Emergency Information report revealed the resident is self responsible. Furthermore, review of R1's medical assessment, conducted on August 13, 2020, does not indicate any substantial cognitive impairment. Therefore, this allegation is deemed UNFOUNDED. A finding that the complaint is unfounded means that the allegation
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 18-AS-20210301135754
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: 03/30/2021
NARRATIVE
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is false, could not have happened, and/or is without a reasonable basis.

An exit interview was conducted with Deoso, in which this report was reviewed and a copy provided.

SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
03/01/2021 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210301135754

FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:GEMMA DEOSOFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 57DATE:
03/30/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Gemma Deoso, AdministratorTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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No one answers the facility phone.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to the facility to deliver the findings of the investigation on the above allegation. The LPA met with Administrator, Gemma Deoso, who was informed of the purpose of the visit.

Regarding the allegation, "No one answers the facility phone," it was alleged a family member of a resident in care was attempting to contact the facility, on or around February 27, 2021, however, facility staff members were not answering the telephone. According to Administrator Deoso, the family member was contacted, and concerns were addressed. No further information was received to corroborate or refute the alleged violation took place. Therefore, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Deoso, in which this report was reviewed, and a copy was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 18-AS-20210301135754
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: 03/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/02/2021
Section Cited
CCR
87465(c)
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Incidental Medical & Dental Care:If the resid.'s physician has stated...that the resident is unable to determine...need for nonprescription PRN medication but can communicate...symptoms clearly, facility staff designated by the licensee are permitted to assist the resident... provided all of the
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The Administrator agreed to schedule a medication audit conducted by a third party agency and submit proof by POC due date.
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following requirements are met: the medication is given according to the physician's directions. This requirement was not as evidenced by: Based on observation the Licensee did not ensure R1's meds were given per the physician's directions. A med. review revealed the 2 meds identified did have additional pills in their packages than scheduled.
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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: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7