331880741-9-20-2024-18-AS-TDAN-D9ATVR-20240920150418

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 04/22/2022
Date Signed: 09/20/2024 02:01:20 PM

Substantiated

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
04/15/2022 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220415083412

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	KURT NIEBRES		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(951) 462-1025
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 64	DATE:	04/22/2022
		UNANNOUNCED	TIME BEGAN:	11:43 AM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Staff not administering resident's medication as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Martinez sent this report to the former licensee's last known mailing address via USPS certified mail to deliver the investigation findings for the above allegation. This facility ceased operations on April 17, 2024.
Regarding the allegation, "Staff not administering resident's medication as prescribed," it was alleged facility staff were administering one of Resident One's (R1's) medications three (3) times a day rather than the prescribed once (1) a day, during the period of March and April 2022. An audit of R1's medications was conducted; seven (7) medications were observed to still have pills available for the March to April 2022 cycle. A third party interview revealed facility staff were supposed to begin despensing R1's medications on March 11, 2022 through April 09, 2022. Administrator Niebres was interviewed; he reported he had conducted an audit of R1's medications and did discover discrepancies. He reported there was five (5) medications R1 did not receive for at least one (1) day due to the medications running out earlier than their scheduled cycles. In addition, a (This is an amended version of the original report created on 04/22/2022. A new LIC 9099 now supersedes it.)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

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-20220415083412

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: 04/22/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/25/2022 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care: If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication...facility staff...shall be permitted to assist the resident..: Once ordered by the physician the medication is given according to	1 2 3 4 5 6 7	The BOM stated in-service training on medication administration will be provided to staff and proof will be submitted to the Department by POC due date.
	8 9 10 11 12 13 14	the physician's directions. This requirement was not met, as evidenced by: Based on interviews, the licensee did not ensure R1's meds. were given according to directions. Niebres reported there were 5 meds. R1 did not receive for at least 1 day due to the meds running out earlier than the scheduled cycles.	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: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220415083412

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: 04/22/2022

NARRATIVE

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review of R1's records revealed a Medication Administration Record (MAR) from April 2022 which suggested four (4) of R1's medications were not being administered at the correct time of day. R1 was interviewed and reported observing only one (1) of her medications to be dispensed to her more than once a day by facility staff. The resident reported this took place for approximately one (1) week. This poses an immediate threat to the resident's health and safety. Therefore, based on interviews and records review, this allegation is deemed SUBSTANTIATED.

A finding that the complaint is substantiated means the allegation is valid because the preponderance of the evidence standard has been met. A citation and civil penalty will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted; this report was reviewed with Business Office Manager (BOM), Jenesa McDonald, and a copy was provided, along with Appeal Rights.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC9099 (FAS) - (06/04)

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