331880741-9-20-2024-18-AS-TDAN-D9AS5F-20240920133416

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 05/17/2023
Date Signed: 09/20/2024 01:17:08 PM

Unsubstantiated

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
05/09/2023 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230509152719

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: 76	DATE:	05/17/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff leaves resident in wheelchair for an extended period of time.

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.

An allegation was received by the Department alleging Resident One (R1) was left in their wheelchair for a long period of time, due to staff failure to assist with transferring. The investigation involved staff/resident interviews, records review, and records collection. An interview with the Wellness Director, Tammy Chavez, revealed R1 did utilize a wheelchair when they were first admitted to the facility. A date of admission and agreed upon services to be provided could not be definitively identified due to R1's admission agreement being found blank. According to Administrator, Kurt Niebres, R1 was admitted to the facility on 03/17/2023.

R1 was interviewed and reported to have been able to get out of their wheelchair on their own, with a lot of difficulty. R1 reported they were left in their wheelchair for longer than they desired; however, the interview

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 782-4807
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-20230509152719

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: 05/17/2023

NARRATIVE

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could not determine a date of when R1 was left in their wheelchair or for how long they remained in their wheelchair without assistance. Staff interviews revealed R1 has always had the capability to transfer to and from their wheelchair since their admission. A Resident Assessment Form, dated March 01, 2023, revealed R1 is able to transfer to their wheelchair on their own. An Appraisal/Needs and Service Plan, dated 05/02/2023, noted R1 uses a wheelchair to get around and is able to transfer independently. R1's Physician's Report for Residential Care Facilities for the Elderly (RCFE) revealed R1 has no motor impairment or paralysis, though an ambulatory status could not be definitively determined based on the report. Two out of the three records reviewed revealed R1 was able to transfer independently.

Information obtained is insufficient to corroborate or refute the validity of the allegation. Therefore, this allegation is deemed UNSUBSTANTIATED at this time. A finding that 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.

It was further alleged that facility staff failed to assist R1 with their medical appointments and failed to address R1's restricted health condition. These allegations were investigated in complaint #18-AS-20230320161847.

A copy of this report was sent to the licensee's last known address via USPS certified mail due to facility closure.

NOTE: This is an amended version of the original report created on 05/17/2023. The findings were changed, and a new LIC 9099 now supersedes it.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 782-4807
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

LIC9099 (FAS) - (06/04)

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