331880741-9-25-2024-18-AS-TDAN-D9FUU7-20240925155257

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 05/10/2023
Date Signed: 09/25/2024 02:10:47 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
01/19/2023 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230119144218

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: 77	DATE:	05/10/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Heater is not working in resident's bedroom

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to continue the investigation into the above allegation. The LPA met with Kurt Niebres, Administrator, and informed him of the purpose of her visit.
A report was received by the Department alleging the heater in Resident One's (R1's) bedroom was not working in January 2023. Staff interview revealed the central heating device connected to R1's bedroom was previously in disrepair around January 2023. R1 was interviewed and stated the temperature in their bedroom has been too cold, on occasion. The LPA toured several rooms and observed that on 01/31/2023, 02/27/2023, and 05/10/2023 the heater was not operable in R1's bedroom or in the surrounding bedrooms. Therefore, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted with Niebres; this report was reviewed and a copy provided, along with instructions on appeal rights. (NOTE: This is an amended version of the original report created on 5/10/23. 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.)

Substantiated

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: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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 4

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
01/19/2023 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230119144218

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: 77	DATE:	05/10/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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9

Staff failed to provide resident with food

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 allegations. This facility ceased operations on April 17, 2024. A report was received by the Department alleging Resident One (R1) was not receiving meals from the facility for two days. The investigation included staff/resident interviews, records review, and records collection. R1 was interviewed and reported they have not received breakfast meals by their own choice. R1 reported not having knowledge of receiving or not receiving other meals throughout the day. A History and Physical report received from R1's medical provider revealed the resident has a cognitive impairment. Two interviews were conducted with dinning staff; both reported R1 does come to the dinning room for meals, though, does not come on occcasion. Neither staff reported having knowledge as to whether R1 would ever receive meals in their bedroom. R1 had no roommate to verify or refute the allegation. Therefore, due to insufficient information, 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. 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 version of the original report created on 05/10/2023)

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: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20230119144218

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: 05/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/31/2023 Section Cited CCR 87303(b)	1 2 3 4 5 6 7	MAINTENANCE AND OPERATION: (b) A comfortable temperature for residents shall be maintained at all times. This requirement was not met as evidenced by: Based on observations, the Licensee did not ensure the temperature in R1's bedroom was comfortable.	1 2 3 4 5 6 7	The Administrator stated the heating unit will be repaired and a statement of certification will be provided.
	8 9 10 11 12 13 14	R1 was interviewed and stated the temperature in their bedroom has been too cold, on occasion. The LPA toured the facility on 01/31/23, 02/27/23, and 05/10/23. The LPA observed the heater not to be operable in R1's bedroom or in the surrounding bedrooms.	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: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC9099 (FAS) - (06/04)

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