331880741-9-20-2024-18-AS-TDAN-D9DKVY-20240923081505

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 09/20/2024
Date Signed: 09/20/2024 04:14:03 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
01/31/2024 and conducted by Evaluator Stephanie Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20240131151911

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	WILLIAMS, MORGAN E		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:	03:26 PM
MET WITH:			TIME COMPLETED:	03:27 PM

ALLEGATION(S):

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Facility elevator is not maintained in good repair.

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 a third-party individual became stuck in the facility elevator in December 2023 for about ten minutes. It was also reported there were multiple times in December 2023 in which the facility elevator was not working. The LPA inspected two out of two elevators at the facility on 02/08/2024 and they both were observed to be in working order. Invoices from an elevator maintenance company were obtained and revealed maintenance services were being provided in December 2023. An interview with the service company was attempted; however, information as to whether appropriate maintenance was being requested by the facility could not be obtained. Staff and resident interviews revealed there have been individuals who have become entrapped in one of two elevators at the facility around February 2024. Staff interviews reported three residents in care have become entrapped in one of two elevators in or

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-20240131151911

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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around December 2023, January 2024, and February 2024. One of three residents could not be identified, the second resident confirmed they were entrapped in an elevator at the facility for about five to ten minutes in or around February 2024, and the third resident denied they were ever entrapped in an elevator at the facility.

Therefore, based on records and interviews, 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.

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)

Page: 2 of 3

Control Number 18-AS-20240131151911

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 B 09/20/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	MAINTENANCE AND OPERATION: (a) The facility shall be clean, safe, sanitary & in good repair at all times. Maintenance shall include provision of maintenance services & procedures for the safety & well-being of residents...& visitors. This requirement was not met, as evidenced by: Based on interviews,	1 2 3 4 5 6 7	This facility ceased operations on April 17, 2024.
	8 9 10 11 12 13 14	the licensee did not ensure the facility was sufficiently maintained for the safety &well-being of residents. Staff and resident interviews revealed there have been individuals who have become entrapped in one of two elevators at the facility.	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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