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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 11/05/2021
Date Signed: 11/05/2021 05:09:08 PM

Unsubstantiated


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
09/01/2021 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210901101814
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: 54DATE:
11/05/2021
UNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Kurt Niebres, ManagerTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility lacks adequate staffing to meet resident needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to deliver the findings on the above allegations. The LPA was greeted by receptionist, Jasmine Singh, and met with Manager, Kurt Niebres. Niebres was informed of the purpose of the visit.

Regarding the allegation, "Facility lacks adequate staffing to meet resident needs," it was alleged only one (1) staff member was available when a resident had fallen and asked a second resident to assist in supervising while they contacted emergency medical services. The LPA initiated the investigation on September 09, 2019; the LPA conducted staff/resident interviews, reviewed records and took copies of pertinent information. Interviews conducted reported Resident One (R1) sustained a fall on or around August 29, 2021 and Staff One (S1) was the only staff member availble at the time of the incident. Interview reported S1 requested the assistance of another resident to supervise R1 so they could contact emergency personnel. R1 was interviewed and denied they had sustained a fall or had been hospitalized. Contact with S1 was attempted, though they could not be reached for interview. Records review was conducted and revealed R1 was hospitalized for a fall on May 21, 2021.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
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 3
Control Number 18-AS-20210901101814
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: 11/05/2021
NARRATIVE
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No written report, with further details, was observed on file by the facility. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

This report was reviewed with Niebdres and a copy provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3