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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 10/06/2023
Date Signed: 10/06/2023 05:02:29 PM


Document Has Been Signed on 10/06/2023 05:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:WILLIAMS, MORGAN EFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 69DATE:
10/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Morgan William, AdministratorTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into complaints 18-AS-20230929111706 and 18-AS-20231003144946. The LPA met with Administrator, Morgan Williams, and informed her of the purpose for the visit.

During the complaint visit the LPA observed at least one resident to be residing on the second floor who require the use of an assistive device to amulate. A record review was conducted; the resident's Physician's Report for Residential Care Facilities for the Elderly (RCFE) revealed the resident is designated non-ambulatory. According to the Riverside City Fire Department, the facility does not have a fire clearance allowing non-ambulatory residents to reside on the second floor at this time. Therefore, based on observation and records, a citation and civil penalty will be issued.

An exit interview was conducted with Business Office Manager (BOM), Crystal Ruelas; this report was reviewed and a copy was provided along with LIC 811 and instructions on appeal rights.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/06/2023 05:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/06/2023
Section Cited
CCR
87203

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FIRE SAFETY: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met, as evidenced by: Based on observation & records, the Licensee didn't ensure the facility was maintained in
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The residents were moved down to the first floor at time of visit.
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conformity with regulations for the protection of life & property. LPA observed 2 residents to be residing on the ND floor who are designated non-ambulatory. The facility does not have a fire clearance allowing non-ambulatory residents to reside on the ND floor at this time.
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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) -24-0313
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023
LIC809 (FAS) - (06/04)
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