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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 01/23/2024
Date Signed: 01/23/2024 05:23:43 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
01/12/2022 and conducted by Evaluator Sara Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20220112142442
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: 67DATE:
01/23/2024
UNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Morgan Williams - Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff do not respond to resident call buttons in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to conclude and deliver findings to an investigation regarding the allegation listed above. LPA was granted entry and met with Executive Director Morgan Williams. The allegation was investigated and consisted of interviews and record review.

Regarding the allegation “Staff do not respond to resident call buttons in a timely manner” it was alleged by reporting party (RP) in January 2022, RP stated when residents push the call button for assistance, staff do not respond in a timely manner. Resident One (R1) stated the facility has “no caregivers” and every time assistance is needed for Resident Two (R2), R1 had to look for staff to assist R2. R1 stated R2 was left on the toilet for more than 30 minutes due to staff not responding to the call button. R2 stated staff take a long time to respond when the call button is pushed. Interview with staff revealed residents would push the call button and the residents would not be attended too in a timely manner due to staff pagers not working.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
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 5
Control Number 18-AS-20220112142442
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: 01/23/2024
NARRATIVE
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Interview with staff and residents revealed there was usually only one caregiver and one MedTech working during a shift to care for the residents. Interview with staff stated it takes an extended amount of time to reach other residents due to the limited number of staff scheduled for each shift. A Situational Awareness and Response Assistant (SARA) log was obtained and reviewed for January 12 2022. Multiple call requests were shown to have lasted for at least thirty minutes. Therefore, based on information obtained through interviews and record review, the allegation “Staff do not respond to resident call buttons in a timely manner” has been deemed SUBSTANTIATED at this time.

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 where a copy of this report was discussed with and provided along with copies of the LIC811, LIC9099C, LIC9099D, and Appeal Rights.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20220112142442
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: 01/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2024
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights (4) To care, supervision, and services that meet individual needs...This did not meet the requirement by:
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Licensee will ensure staff are trained and will respond to residents call button reuqest in a timely manner and provide in-service training by the POC date.
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Based on interview and record review, the Licensee did not ensure staff responded to residents' call button request in a timely manner which is a potential health and safety risk to 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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
01/12/2022 and conducted by Evaluator Sara Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20220112142442

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: DATE:
01/23/2024
UNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Morgan Williams - Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff yell at residents in care
Residents do not receive balanced meals
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to conclude and deliver findings to an investigation regarding the allegation(s) listed above. LPA was granted entry and met with Morgan Williams. The allegation was investigated and consisted of observation, interviews, and record review.

Regarding the allegation “Staff yell at residents in care”, Reporting Party (RP) stated they heard staff yelling at residents and that yelling at residents is a constant behavior by staff. Interview with Resident One (R1) revealed they did not know anything about staff yelling at residents. Staff One (S1) stated they have never heard staff yelling at the residents. Staff Two (S2) stated while they were on the clock working as a caregiver or MedTech, they never witnessed staff yelling at residents. S2 stated if they did hear staff yelling at a resident, they would report it. Therefore, based on information obtained from interviews, the allegation has been deemed UNSUBSTANTIATED at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20220112142442
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: 01/23/2024
NARRATIVE
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Regarding the allegation “Residents do not receive balanced meals” it was reported facility does not serve salads or any balanced meals. RP stated the facility served the residents rice and beans for dinner. Interview with R1 revealed they were served brown rice, beans, and a shredded beef soup for a meal. Regarding if R1 thought the meal was balanced, R1 stated “I would say it was balanced”. Resident Two (R2) reported they remembered when the rice, beans, and soup was served but R2 does not eat rice. R2 stated the meal was enough for R2. Resident Three (R3) stated they served rice, beans, and soup for dinner but R3 chose to eat the alternative meal of a sandwich instead. Interview with a resident revealed the facility does not provide balanced meals. Interviews with staff stated the meals being well-balanced were “on and off”. Staff interviews revealed when the facility runs out of the prepared meal for the residents, the facility would serve an alternative chicken sandwich or peanut butter and jelly sandwich. Facility’s food supply of perishable and non-perishable foods during the initial visit in 2022 was not documented or observed. Records review of facility’s menu from January 2022 could not be conducted due to records retention time frame. LPA requested to see the current menu available for the facility and reviewed a balanced meal plan for breakfast, lunch, and dinner with adequate amount of snacks available for residents in care. LPA attempted to contact cooks who worked at the facility in 2022 but did not receive a response. Therefore, based on LPA’s information obtained from interviews, the allegation has been deemed UNSUBSTANTIATED at this time.

A finding 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 the alleged violation occurred. An exit interview was conducted and copy of this report along with LIC-811 Confidential Names List was provided to Morgan Williams.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5