331880741-9-18-2024-18-AS-TDAN-D9AVAM-20240920161609

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 09/18/2024
Date Signed: 09/18/2024 04:43:14 PM

Unfounded

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 COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	BERCOVICH, MOISES U		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(951) 462-1025
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	0	CENSUS: 0	DATE:	09/18/2024
		UNANNOUNCED	TIME BEGAN:	03:44 PM
MET WITH:			TIME COMPLETED:	04:43 PM

ALLEGATION(S):

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Facility is not allowing residents to chose their medical providers

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.

A report was received by the Department alleging the facility was pressuring Resident One (R1) to change their current healthcare program to another provider. The investigation included staff and resident interviews, records review, and collection of relevant documentation. R1 was interviewed and reported they were not told about changing their healthcare program. R1 reported wanting to remain under the current program they were with. According to the facility's board member, Adam Zenou, the facility previously maintained a contract with the healthcare program in question; however, the program cancelled the contract in July 2023. Zenou reported the rates offered by the program, when a new contract was discussed, were not sufficient to cover the operational costs of the facility. He reported a new contract could not be arranged with program. A third-party representative with R1's healthcare program reported the previous contract with the facility was cancelled. The

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

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-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: 09/18/2024

NARRATIVE

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interview with the representative corroborated Zenou's statement regarding a new contract not being able to be arranged.

In addition, a letter was obtained which revealed a notice was given to residents regarding the cancelation of the original contract. The letter, dated 08/31/2023, indicated residents were given the option to remain with their original healthcare program or to change to another provider who would be able to cover the cost of their rent and care.

Therefore, based on interviews and records, this allegation is deemed UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

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

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC9099 (FAS) - (06/04)

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