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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 09/08/2023
Date Signed: 09/20/2024 08:32:39 AM

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
08/31/2023 and conducted by Evaluator Stephanie Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230831074101
FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:BERCOVICH, MOISES UFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 64DATE:
09/08/2023
UNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Morgan Williams, AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility overcharged resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Administrator, Morgan Williams, and informed her of the purpose for her visit.

The investigation included staff and resident interviews, review of records, and receipt of relevant documentation.

A report was received by the Department alleging Resident One (R1) was billed a higher rate for the month of July 2023 than was initially agreed upon. R1 was interviewed, reported they do not handle their own finances, and referred any questions to their responsible party (RP). An interview with R1's RP revealed R1 was charged $1,324 in July 2023; however, they should have been charged $1,200. The LPA reviewed the admission agreement on file for R1; the document revealed there was no documented rate for care and services agreed upon by R1's RP and the facility. Therefore, due to a lack of information, this allegation is deemed
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (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)
Page: 1 of 3
Control Number 18-AS-20230831074101
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: 09/08/2023
NARRATIVE
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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.

This report was reviewed with Administrator Williams and a copy was provided.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3