331880741-9-21-2024-18-AS-TAGD-D9HP63-20240927110136

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 09/21/2024
Date Signed: 09/21/2024 02:24:29 PM

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
11/02/2022 and conducted by Evaluator Gina Saucedo

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20221102162529

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: 102	DATE:	09/21/2024
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Molly Bowie, Executive Director		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility staff are not safeguarding resident medications

INVESTIGATION FINDINGS:

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On 09/21/24, at 9:05am, Licensing Program Analyst (LPA) Gina Saucedo conducted a subsequent complaint visit to the facility to conclude the investigation regarding the above allegation. The ten day visit was made by LPA Stephanie Torres on 11/04/22.

During today's visit, LPA Saucedo met with the Executive Director, Molly Bowie, and advised them of the allegation(s). LPA Saucedo conducted additional resident and staff interviews and conducted a physical plant tour.

LIC 9099-continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2024

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 5

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
11/02/2022 and conducted by Evaluator Gina Saucedo

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20221102162529

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: 102	DATE:	09/21/2024
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Molly Bowie, Executive Director		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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9

Facility staff are not administering resident's medication as prescribed

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2024

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 5

Control Number 18-AS-20221102162529

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: 09/21/2024

NARRATIVE

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Regarding the allegation: Facility staff are not administering resident’s medication as prescribed. It is being alleged that residents are not receiving their medication. NIne (9) out of ten (10) residents confirmed that they are missing their medication. Resident #1 (R1) confirmed that they were missing five (5) medications, R3, R4 and R6 were missing pain medication and R5 was missing their insulin for their diabetes. The rest of the residents confirmed that there has been a shortage of staff in the past and this was one of main reasons their medication was not being administered as prescribed. Three (3) staff also confirmed that there has been a shortage of staff and this was one (1) of the main reasons why the medication was not being administered as prescribed. Therefore, based on the LPA's observations, staff and resident interviews the above allegation above is SUBSTANTIATED at this time.

An exit interview was conducted, Appeals Rights, citation(s) were issued for the above allegation(s), and a copy of this report was given to the Executive Director.

Due to facility closure on April 15, 2024, a copy of this report and appeal rights (LIC 9058 1/16) will be sent via email to Adam Zenou at Adam@skilledmanagementco.com and another certified copy via USPS to Mr Zenou's at his last known address.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 18-AS-20221102162529

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: 09/21/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/22/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...routine medical and dental care ... assistance in obtaining such care, by compliance with the following:(4)The licensee shall assist residents with self-administered medications..This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The licensee/administrator will ensure that all prescribed medication are administered to all residents and ensure that all staff are trained properly on administering resident medication. The training will be sent to LPA. POC 09/22/24
	8 9 10 11 12 13 14	Based on the observation, interviews and record reviews, the licensee did not ensure 9 out of 10 residents at the facility to receive their prescribed medication, which poses in immediate Health, Safety or Personal Rights risks to person in care.	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: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 18-AS-20221102162529

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: 09/21/2024

NARRATIVE

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Regarding the allegation: Facility are not safeguarding resident medication. It is being alleged that one (1) of the residents handles own medication. LPA attempted to obtain Resident #1 (R1)'s physician's report to determine whether or not R1 was able to administer and keep their medication and/or if there is a doctor's order for R1 to keep own medication and per the current Executive Director, no record exist for R1 or any resident prior to current Licensee's takeover on July of 2023. LPA was not able to interview Resident #1 (R1) because they are not longer at the above facility. Nine (9) out of ten (10) residents confirmed that their medication is centrally stored for them and they do not handle their own medication. Three (3) staff also confirmed that the resident's medication is kept in a cart where the medication is kept and then distributed for them. Therefore, based on the LPA's observations, staff and resident interviews the above allegation(s) above is UNSUBSTANTIATED at this time.

An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Executive Director.

Due to facility closure on April 15, 2024, a copy of this report and appeal rights (LIC 9058 1/16) will be sent via email to Adam Zenou at Adam@skilledmanagementco.com and another certified copy via USPS to Mr Zenou's at his last known address.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2024

LIC9099 (FAS) - (06/04)

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