331880741-3-14-2024-18-AS-RSTS-D4U268-20240430170641

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 03/14/2024
Date Signed: 03/14/2024 04:32:06 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
10/03/2023 and conducted by Evaluator Stephanie Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20231003144946

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	BERCOVICH, MOISES U		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(951) 462-1025
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 73	DATE:	03/14/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Morgan Williams, Administrator		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Facility staff could not be found in the facility
Residents were not provided with their medication

INVESTIGATION FINDINGS:

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Regional Manager, Reyna Lacey, and Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to continue the investigation into the above allegations. The LPA met with Administrator, Morgan Williams, and Co-Licensee, Adam Zenou, and informed them of the purpose for their visit.

The investigation included staff/resident interviews, a review of records, and collection of relevant documentation.

A report was received by the Department alleging no staff were present at the facility on or around 09/29/2023 at about 10:00 PM. Resident interviews reported it is unknown whether staff were present at the facility on 09/29/2023. Administrator Williams was interviewed and reported three staff members were scheduled to work on 09/29/2023. A staff schedule was reviewed and revealed staff were assigned to work the night shift on 09/29/2023. No additional information was available to corroborate or refute the allegation. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

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-20231003144946

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: 03/14/2024

NARRATIVE

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A second report was received alleging Residents One (R1) and Two (R2) did not receive their medications on or around 09/29/2023, due to a lack of staff at the facility. Records were requested for R1; however, the records could not be produced for review by the LPA. R1 could not be reached, prior to the conclusion of the investigation. A copy of R2's Medication Administration Record (MAR) was obtained and suggested medications may not have been administered as no one signed off on 09/29/2023. R3 was interviewed and reported the do not recall if they had missed any medications on or around 09/29/2023. No additional information was available to corroborate or refute the allegation. Therefore, due to a lack of information, 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 violations occurred.

An exit interview was conducted; this report was reviewed with Administrator Williams and a copy was provided.

NOTE: CCL personnel were off site from 12:30 PM to 1:45 PM.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC9099 (FAS) - (06/04)

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