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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 04/06/2021
Date Signed: 04/06/2021 10:42:12 AM



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
08/31/2020 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200831095737
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: 58DATE:
04/06/2021
UNANNOUNCEDTIME BEGAN:
07:50 AM
MET WITH:Gemma Deoso, AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Unqualified staff administering insulin to residents
Lack of staff to care for residents



INVESTIGATION FINDINGS:
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This unannounced visit conducted by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegations mentioned above.

During the course of the investigation LPA toured the food supply and kitchen, interviewed staff, reviewed resident records and obtained copies of pertinent documents which include: resident medical assessments, resident roster and staff schedule. LPA learned the following information: Concerning the allegation "Unqualified staff administering insulin to residents", it is alleged that medication technicians are dispensing insulin. During investigation LPA learned that three residents receive insulin injections. LPA determined through review of resident records and through interviews that medication technicians are filling insulin syringes from insulin bottles for two of three residents receiving insulin and injecting insulin for residents.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
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
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
08/31/2020 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200831095737

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: 58DATE:
04/06/2021
UNANNOUNCEDTIME BEGAN:
07:50 AM
MET WITH:Gemma Deoso, AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Facility not maintained at a comfortable temperature
Kitchen is unsanitary
INVESTIGATION FINDINGS:
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12
13
This unannounced visit conducted by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegations mentioned above.

During the course of the investigation LPA toured resident bedrooms, the kitchen, assessed the facility foood supply, interviewed staff, reviewed resident records and obtained copies of pertinent documents. LPA learned the following: Concerning the allegation,"Facility not maintained at a comfortable temperature", it is alleged that a portion of the facility on the side of the parking garage does not have air. LPA determined that rooms 100 through 108 would have been the affected rooms. LPA toured the rooms and noted a comfortable temperature. This portion of the rooms are controlled by a central thermostat and maintatined at 78 degrees. LPA observed the thermostat and the set temperature.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20200831095737
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: 04/06/2021
NARRATIVE
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Currently rooms 100, 104, and 108 are not occupied by residents. Interviews revealed that the air conditioning has been functioning adequately to maintain a comfortable temperature.

Concerning the allegation," Kitchen is unsanitary", It is alleged that the kitchen is very messy, that containers are opened and not labeled, drains are not cleaned, and the food supply is inadequate. Investigation included LPA touring the kitchen and food supply while in the facility on 02/23/2021, 02/25/2021, 03/04/2021, and 04/06/2021. LPA did not observe that the food supply was inadequate or that the kitchen is unsanitary on the dates noted.

We have found the complaint allegations are unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20200831095737
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: 04/06/2021
NARRATIVE
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Concerning the allegation,"Lack of staff to care for residents", interviews conducted revealed that on most night shift there is one staff for the total of the care giving and medication dispensing and that staff are slow to respond to or do not respond to the call signal system at all.

We have substantiated the complaint allegations as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20200831095737
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/07/2021
Section Cited
CCR
87628(a)
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 The licensee shall be permitted to accept or retain a resident who has diabetes if... or has it administered by an appropriately skilled professional. The facility has failed to meet this requirement as evidenced by:
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All medication technicians were retrained on 03/30/2021 by Santa Maria Pharmacy and the practice has ceased. The facility has hired one LVN. Plan for retraining all the medication technicians
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Interviews conducted confirming medication technicians are filling insulin syringes from insulin bottles for two of three residents receiving insulin and injecting insulin for residents. This poses a risk to the health and safety of residents in care.
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and available training record along with LVN employment verification to be submitted to LPA by 04/07/2021.
Type A
04/07/2021
Section Cited
CCR
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. The facility has failed to meet this requirement as evidenced by:
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Administrator has hired additional staff and will provide staffing schedule to verify adequate staffing along with back up plan for to meet staffing needs.
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Based on interviews conducted it was revealed that on night shifts there is one staff for the care giving and medication dispensingcand that staff are slow to respond to or do not respond to the call bell at all. This poses a risk to the healthand safety of 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: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5