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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 12/13/2021
Date Signed: 12/13/2021 05:47:25 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: 58DATE:
12/13/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:BOM, Jenesa McDonaldTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Resident was not provided with breakfast
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounved visit to the facility to deliver the findings of the investigation into the above allegations. The LPA was greeted by Business Office Manager, Jenesa McDonald, and met with Administrator, Kurt Niebres. Niebres was informed of the purpose of the visit.

Pertaining to the allegation, "Resident was not provided with breakfast," it was alleged the facility failed to provide a breakfast meal to residents in care. The LPA initiated the investigation on September 09, 2021; staff/resident interviews were conducted, records reviewed and copies of pertinent information were obtained. Interviews conducted could not corroborate or refute the validity of the violation. 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 violation occurred. This report was reviewed with BOM McDonald and a copy was provided.
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: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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 4
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: 58DATE:
12/13/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:BOM, Jenesa McDonaldTIME COMPLETED:
05:45 PM
ALLEGATION(S):
1
2
3
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5
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9
Facility has bed bugs
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounved visit to the facility to deliver the findings of the investigation into the above allegations. The LPA was greeted by Business Office Manager, Jenesa McDonald, and met with Administrator, Kurt Niebres. Niebres was informed of the purpose of the visit.

Pertaining to the allegation, "Facility has bed bugs," it was alleged facility staff have done nothing to mitigate the infestation of bed bugs, causing the insects to spread to multiple bedrooms. The LPA initiated the investigation on September 09, 2021. The LPA observed bedbugs at the facility on September 09, 2021 and on December 13, 2021. Interviews were conducted and it was reported at least two (2) residents have been affected by the infestation. Administrator Niebres was interviewed and confirmed bedbugs were observed in several bedrooms and a pest control company was contacted and serviced the areas. No service requests were found showing whether any resident bedrooms were treated in the last five (5) months. Therefore, based on observation and interviews, this allegation is deemed SUBSTANTIATED. An exit interview was conducted with with BOM McDonald. A copy of this report was provided, along with Appeal Rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2021
Section Cited
CCR
87307(d)(2)
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Personal Accommodations & Services: The following space & safety provisions shall apply to all facilities: The premises shall be maintained in a state of good repair & shall provide a safe & healthful environment. This requirement wasn't met as evidenced by: Based on observation & interviews the
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BOM McDonald provided proof of treatments provided by an extermination company. POC cleared.
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Licensee didn't ensure a safe & healthful environment was provided.
LPA observed bedbugs at the facility. Interviews reported residents have been affected. Proof of treatment wasn't observed. This poses a potential threat to the 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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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: 12/13/2021
NARRATIVE
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 substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted with with BOM McDonald. A copy of this report was provided, along with Appeal Rights.

SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4