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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 06/12/2024
Date Signed: 06/12/2024 09:28:43 AM

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
03/03/2022 and conducted by Evaluator Sara Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20220303100807
FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:KURT NIEBRESFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:0CENSUS: 92DATE:
06/12/2024
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Executive Director - Morgan Williams TIME COMPLETED:
09:35 AM
ALLEGATION(S):
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Facility did not safeguard resident's belongings
Facility failed to provide resident with a bed
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 allegations listed above. LPA was granted entry and met with Executive Director Morgan Williams. The allegation was investigated and consisted of interviews.

Regarding the allegation “Facility did not safeguard resident's belongings” it was reported due to a bed bug infestation, Resident One (R1) had their personal belongings removed from the room and thrown away. R1’s personal belongings included clothing and electronics. Interview with R1 reported their TV, DVDs, and clothes taken from their room. R1 reported their TV was returned after R1 was transferred to a new room. R1’s clothing was thrown away and not returned. Records review of R1’s file was not conducted due to records not being maintained for the required retention time. LPA conducted interviews with three (3) residents who resided at the facility during the time this complaint was received. One (1) of three (3) residents interviewed reported having their personal belongings thrown away and not replaced by the facility due to the bed bug infestation.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
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 4
Control Number 18-AS-20220303100807
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: 06/12/2024
NARRATIVE
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LPA attempted to interview former Administrator regarding the facility’s policy and procedures regarding a bed bug infestation and resident’s personal belongings, but an interview could not be conducted due to Administrator not returning LPA’s multiple attempts of contact. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 12, Chapter 1), are being cited on the attached LIC 9099 D.

Regarding the allegation “Facility failed to provide resident with a bed” it was reported due to a bed bug infestation, R1 had their bed removed from their room and R1 had to sleep on a recliner for an unknown number of days. Interview with R1’s Responsible Party reported R1 had their bed removed from their room on Friday 02/25/2022 and R1 was informed they would receive a new bed on Monday 02/28/2022. R1’s responsible party was informed on 03/03/2022 R1 would receive a new bed that same day. Interview with R1 revealed they had slept on the recliner for approximately two weeks before moving into a new room due to the bed bug infestation. LPA attempted to interview former Administrator, but an interview could not be conducted due to Administrator not returning LPA’s multiple attempts of contact. LPA conducted an interview with Resident Two (R2) who had a bed bug infestation during the same time as R1. R2 reported the facility provided R2 with a bed after their bed was removed due to the bed bug infestation but was unable to verify of R1 was provided with a new bed. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 12, Chapter 1), are being cited on the attached LIC 9099 D.

An exit interview was conducted with Executive Director Morgan Williams and a copy of this report along with the LIC 9099D, LIC 811 - Confidential Names, and appeal rights were provided.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20220303100807
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: 06/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/19/2024
Section Cited
CCR
87217(b)
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87217 Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents'...personal property and valuables which have been entrusted to the licensee or facility staff.... This requirement was not met as evidence by:
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Licensee agrees to review the regulation cited for safeguard of resident cash, property, and valuables. Licensee shall submit statement of understanding of regulations reviewed by end of POC due date.
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Based on interviews conducted, the Licensee did not comply with the above regulation with at least one resident (R1). LPA confirmed that R1 had their personal belongings thrown away due to bed bug infestation which poses a potential health, safety, or personal rights risk to persons in care.
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Type B
06/19/2024
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by:
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Licensee agrees to ensure residents will be provided with a bed when requested. Licensee shall submit statement of understanding of regulations reviewed by end of POC due date.
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Based on interviews conducted, the Licensee did not comply with the above regulation with at least one resident (R1). R1 had gone an unknown number of days without a bed and slept on a recliner due to a bed bug infestation which poses a potential health, safety, or personal rights risk to persons 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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
03/03/2022 and conducted by Evaluator Sara Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20220303100807

FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:KURT NIEBRESFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:0CENSUS: DATE:
06/12/2024
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Executive Director - Morgan Williams TIME COMPLETED:
09:35 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to accomodate resident with an appropriate mattress
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to conclude and deliver findings to an investigation regarding the allegations listed above. LPA was granted entry and met with Executive Director Morgan Williams. The allegation was investigated and consisted of interviews.

Regarding the allegation “Facility failed to accommodate resident with an appropriate mattress” it was reported Resident One (R1) had received a mattress from the facility with a hole in it. Interview with R1’s Responsible Party revealed R1’s mattress did not have a hole; the mattress had a dent in it and was worn out. Interview with R1 revealed the mattress did not have a hole in but was worn out. LPA conducted interviews with three (3) residents who resided at the facility during the time this complaint was received. Three (3) of three (3) residents interviewed reported they were accommodated with an appropriate mattress at the time of their admission. LPA attempted to interview former Administrator, but an interview could not be conducted due to Administrator not returning LPA’s multiple attempts of contact. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report and LIC 811 - Confidential Names, was provided to Executive Director Morgan Williams.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
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 4