331880741-9-22-2023-18-AS-RSTS-D5UM4S-20240602091709

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 09/22/2023
Date Signed: 09/22/2023 02:04:52 PM

Substantiated

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
09/15/2023 and conducted by Evaluator Stephanie Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230915084347

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: 67	DATE:	09/22/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Morgan Williams, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility personnel accepted power of attorney for resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Administrator, Morgan Williams, and informed her of the purpose for the visit.

A report was received by the Department alleging Staff One (S1) illegally became the Power of Attorney (POA) for Resident One (R1) by using another resident, Resident Two (R2) as a witness to the agreement. No staff file was available for S1; however, staff interviews revealed S1 was an employee of the facility and worked as a caregiver, activities director, maintenance worker, and administrator's assistant throughout their employment. Staff interviews reported S1 was working in the facility in 2021. During a record review, a document (Durable Power of Attorney) was observed on file revealing S1 was designated as the POA for R1 on December 15, 2021. The POA document grants S1 with General Authority, including, Banking and other financial Institute transactions and Benefits from Social Security. Regulatory requirements do not allow employees in Residential

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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-20230915084347

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: 09/22/2023

NARRATIVE

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Care Facilities for the Elderly (RCFE) to accept any general or special power of attorney for any such person.

This poses a potential threat to the health, safety, and personal rights of the resident in care. Therefore, based on interviews and records, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted; this report was reviewed with Administrator Williams and a copy was provided, along with LIC 811, and instructions on appeal rights.

NOTE: The Licensee incorporated a new management company into the LLC to oversee operation of the facility. The new management company has been operating the facility since July 01, 2023.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20230915084347

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/29/2023 Section Cited CCR 87217(d)(2)	1 2 3 4 5 6 7	SAFEGUARDS FOR RESIDENT CASH, PERSONAL PROPERTY, AND VALUABLES: (d) Except as provided in approved continuing care agreements, no licensee or employee of a facility shall: (2) accept any general or special power of attorney for any such person; This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	The Administrator stated all resident files will be reviewed to identify which residents have a POA and verify the agent was not a current or previous staff member of the facility. She stated a statement of certification would be submitted to the Department.
	8 9 10 11 12 13 14	Based on interviews and records, the Licensee did not ensure an employee did not accept a power of attorney for a resident in care. Staff interviews revealed S1 was an employee of the facility in 2021. A Durable Power of Attorney was observed on file revealing S1 was designated as the POA for R1 on 12/15/21.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Stamps	TELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC9099 (FAS) - (06/04)

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