331880741-9-20-2024-18-AS-TDAN-D9ATVQ-20240920150418

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 09/20/2024
Date Signed: 09/20/2024 02:08:46 PM

Substantiated

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
04/15/2022 and conducted by Evaluator Stephanie Martinez

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:	0	CENSUS: 0	DATE:	09/20/2024
		UNANNOUNCED	TIME BEGAN:	10:49 AM
MET WITH:			TIME COMPLETED:	10:50 AM

ALLEGATION(S):

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Staff did not re-order medication

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.

Pertaining to the allegation, "Staff did not re-order medication," it was alleged one of R1's medications finished without a refill being delivered. An audit of R1's medications was conducted; sevem (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; Niebres reported he had conducted an audit of R1's medications and did discover discrepancies. He reported there were five (5) medications R1 did not receive for at least one (1) day due to the medications running out earlier than their scheduled cycles. Niebres reported it is unknown why the medications ran out prior to their scheduled refill. Third party interviews reported all of R1's medications are refilled automatically, if they are administered appropriately, and therefore the facility does not need to call to

Substantiated

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: 09/20/2024

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-20220415083412

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: 09/20/2024

NARRATIVE

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request a refill. The medications ran out before the scheduled refill, and staff did not request an interim refill. Therefore, based on interviews and observation, this allegation is deemed SUBSTANTIATED, at this time. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

A copy of this report, and appeal rights were sent to the licensee's last known address via USPS certified mail due to facility closure.

NOTE: This is an amended report and the findings have been changed.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
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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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
RIVERSIDE ASC, 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: 09/20/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/20/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	Incidental Medical and Dental Care: (a) A plan for incidental medical & dental care shall be developed by each facility. The plan shall encourage routine medical & dental care & provide for assistance in obtaining such care, by compliance w/ the following: (4) The licensee shall assist residents w/	1 2 3 4 5 6 7	R1 is no longer residing at the facility and the facility is no longer in operation.
	8 9 10 11 12 13 14	self-administered medications as needed. This requirement was not met, as evidenced by: Based interviews, the Licensee did not ensure R1 was assisted with self-administration of medications as needed. Administrator reported there were 5 medications R1 didn't receive...due to the medications running out...	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: Rikesha Stamps	TELEPHONE: (951) -212-0616
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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC9099 (FAS) - (06/04)

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