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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 01/23/2024
Date Signed: 01/23/2024 05:15:06 PM

Substantiated


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
10/22/2021 and conducted by Evaluator Sara Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20211022122606
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: 67DATE:
01/23/2024
UNANNOUNCEDTIME BEGAN:
02:27 PM
MET WITH:Executive Director - Morgan WilliamsTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff are not meeting the needs of the residents.
Staff are not providing adquate supervision.
Bedrooms are dirty.
The rugs are dirty.
Food service is inadquate.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to conclude and deliver findings to an investigation regarding the allegation(s) listed above. LPA was granted entry and met with Executive Director Morgan Williams. The allegation was investigated and consisted of observation, interviews, and record review.

Regarding the allegation “Staff are not meeting the needs of the residents”, Interview with Resident One (R1) revealed the facility has “little staffing” and only “one or two staff are present on the weekends”. Staff interviews revealed it takes longer to assist residents due to staff needing to continuously go to the facility’s computer system to identify call button request form residents due to additional staff not being available to assist residents. Interviews with staff revealed there are days when there would only be one MedTech and one caregiver on the floor. Staff stated MedTechs would help with caregiving to assist with responding to residents requesting assistance.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
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 5
Control Number 18-AS-20211022122606
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: 01/23/2024
NARRATIVE
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Staff stated in an interview “60 percent of the time it would be two to three caregivers on the floor” so it would take more time to assist other residents due to limited staff and the number of residents the facility had. Record review of Resident Two(R2) Appraisal/Needs and Services Plan stated “Resident needs assistance with activities of daily living” and “Resident needs assistance of two (2) staff for transfer due to safety”. Due to the number of staff scheduled and the number of residents who need assistance with activities of daily living, staff are not meeting the needs of the residents. Therefore, based on interviews the allegation “Staff are not meeting the needs of the residents” has been deemed SUBSTANTIATED at this time.

Regarding the allegation “Staff are not providing adequate supervision”, Reporting Party (RP) stated there is never enough staff to assist the residents. RP stated a non-ambulatory resident was left on the toilet for approximately two (2) hours on three (3) separate occasions. RP would call the facility to inform staff that the resident needed assistance but staff at the facility would not answer the phone. During a visit on 10/22/2021, LPA pressed a call button located in the bathroom in room #143 and the facility’s receptionist arrived to assist with caregiving. Receptionist reported to LPA they were “just helping out” due to lack of staff. Therefore, based on interviews and observation, the allegation “Staff are not providing adequate supervision” has been deemed SUBSTANTIATED at this time.

Regarding the allegation “Bedrooms are dirty ”, LPA observed multiple bedrooms that were not clean and sanitary during visit on 10/22/2021. Room # 141 had a strong urine smell and LPA observed soiled diapers in the sink in the resident’s bathroom. RP stated the bedrooms have tissues and trash on the floor. LPA observed R2 bedroom’s carpet stained in several areas. Therefore, based on interviews and observation, the allegation “Bedrooms are dirty” has been deemed SUBSTANTIATED at this time.

Regarding the allegation “The rugs are dirty”, interview with R3 revealed they are aware of the carpet stains in resident bedrooms and facility hallways.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20211022122606
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: 01/23/2024
NARRATIVE
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R3 stated the stains are urine stains due to the smell. LPA observed stains in multiple resident bedrooms. Staff One (S1) stated the carpets were stained but does not know the cause of the stains. Interview with Administrator Kurt Niebres revealed the facility cleans the hallway floors but not the residents’ bedroom floors. Therefore, based on interviews and observation, the allegation “The rugs are dirty” has been deemed SUBSTANTIATED at this time.

Regarding the allegation “Food service is inadequate”, it was alleged the food served to the residents is disgusting and the meat texture is tough for the residents to chew.
Interview with staff and residents revealed the facility had served uncooked chicken or meat with texture too tough for the residents to chew. Interview with residents revealed residents have received undercooked hamburger patties and chicken that still had blood in it. Interviews with residents revealed due to special dietary needs, they are not able to eat the majority of the meals served due to the facility serving meals containing noodles, potatoes, and rice. The only alternative the facility gives to the residents are sandwiches. Interview with staff revealed the facility food service staff do not show up until late in the day and the “residents live off of sandwiches”. Interview with staff and Administrator Kurt Niebres revealed the facility has no staff who are either a nutritionist, a dietician, or a home economist, nor do they receive consultative services from a person qualified as required by Title 22 regulations for a facility licensed for fifty (50) or more residents. Therefore, based on interviews the allegation “Food service is inadequate” has been 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 where a copy of this report was discussed with and provided along with copies of the LIC811, LIC9099C, LIC9099D, and Appeal Rights.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20211022122606
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1... residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual...This requirement was not met as evidenced by:
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Licensee will ensure facility staff are trained and will be adequately staffed to meet the individual needs and services of the residents while in care.
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Based on interviews and record review, the Licensee did not ensure staff were meeting the individual needs and service of the residents while in care due to lack of staffing which poses a potential health or safety risk to residents in care.
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Type B
01/30/2024
Section Cited
CCR
87411(a)
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87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…This requirement is not met as evidenced by:
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Licensee will ensure facility is adequately staffed and will be able to meet the individual needs and services of the residents while in care.
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Based on interviews and observations, the licensee did not ensure facility personnel to be sufficient in numbers and competent to provide the services necessary to meet resident needs while in care. This is a potential health and safety risk to 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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20211022122606
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2024
Section Cited
CCR
87303(a)
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7303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors… This requirement is not met as evidenced by:
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Licensee will ensure the facility and resident's bedrooms to be clean, safe, and sanitary at all times.
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Based on interviews and observations, the licensee did not ensure facility be clean and sanitary for residents in care. This is a potential health and safety risk to residents in care.
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Type B
01/30/2024
Section Cited
CCR
87555(b)(17)
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87555 General Food Service Requirements (b) The following food service requirements shall apply: (17) In facilities licensed for fifty (50) or more... a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service.... This requirement is not met as
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Licensee will ensure a nutritionist or dietary consultant will be obtained to create menu plan for residents in care.
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Based on interviews and record review, the licensee did not ensure facility had a hired nutritionist or dietary consultant for the residents in care. This is a potential health and safety risk to 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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5