331880741-1-10-2023-18-AS-RSTS-D53MKW-20240508094123

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 01/10/2023
Date Signed: 01/10/2023 01:20:33 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
01/04/2023 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230104110943

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	KURT NIEBRES		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(951) 462-1025
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 76	DATE:	01/10/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility staff were not present at facility
Facility staff are not removing trash from resident rooms

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to continue the investigation into the above allegations. The LPA met with Kurt Niebres and informed him of the purpose of the visit.

The LPA started the investigation on January 05, 2023; the LPA obtained copies of pertinent documentation and conducted staff/resident interviews.

Facility staff were alleged to not have been present to provide care and supervision to residents on December 25, 2022. Eight interviews were conducted; three individuals reported staff were present, two reported staff were not present and three reported they were not aware. A detail report was received that revealed three care staff were present for both the day and night shifts on December 25, 2022. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

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-20230104110943

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: 01/10/2023

NARRATIVE

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Additionally, it was reported staff are not removing trash from resident bedrooms. Eight interviews were conducted; seven individuals reported staff do remove trash from resident bedrooms; however, it was also reported residents remove their own trash willingly and/or need to remind staff to remove trash from their bedrooms. 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 allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations occurred.

This report was reviewed with Niebres and a copy was provided.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

LIC9099 (FAS) - (06/04)

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