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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 09/22/2024
Date Signed: 09/22/2024 02:50:33 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
01/27/2022 and conducted by Evaluator Gina Saucedo
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220127101012
FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:GEMMA DEOSOFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:0CENSUS: 102DATE:
09/22/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Molly Bowie, Executive DirectorTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Resident's medication is running low prior to refill
INVESTIGATION FINDINGS:
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On 09/22/24, at 9:10am, 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 02/01/22.

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 AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2024
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
Control Number 18-AS-20220127101012
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: 09/22/2024
NARRATIVE
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Regarding the allegation: Resident's medication is running low prior to refill. It is being alleged that residents medication is not being refilled on time. LPA attempted to obtain R1's physician's report to determine their medical diagnosis and what medication was running low prior to refill but per the current Executive Director there is no record that exists for R1 or any resident prior to current Licensee's takeover in July of 2023. Although ten (10) out of ten (10) residents did confirm that their medication does run out sometimes, it was also confirmed by two (2) staff that the reason the medication runs low prior to refill is because the refill can only be done within 5-7 days prior to the prescription running out. The staff continued to say that there is a cycle for a prescription refill. The prescription is given by the doctor then it is sent via fax or/and E-script to the pharmacy and then the pharmacy fills the prescription upon insurance approval. One (1) of the staff did state that they try their best to make the process faster by making phone calls and speeding up the process but that is not always possible. One (1) of the residents did state that their pharmacy is called Market Pharmacy and they do take long to authorize their refills for medication.
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 AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 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
01/27/2022 and conducted by Evaluator Gina Saucedo
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220127101012

FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:GEMMA DEOSOFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:0CENSUS: 102DATE:
09/22/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Molly Bowie, Executive DirectorTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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9
Facility staff are not administering resident's medications as prescribed
INVESTIGATION FINDINGS:
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On 09/22/24, at 9:10am, 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 02/01/22.

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
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20220127101012
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: 09/22/2024
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 when prescribed. Resident #1 (R1) no longer resides at the facility and their records could not be obtained. LPA attempted to obtain R1's physician's report to determine their medical diagnosis and what medication was missing and/or what medication they were being administered but per the current Executive Director has no record that exists for R1 or any resident prior to current Licensee's takeover in July of 2023. Ten (10) out of ten (10) residents confirmed that they have missed their medication or/and their medication is not given on time. In addition, LPA randomly did a Medication Administration Record (MAR) review of resident’s records that shows medication was missed. Some residents did confirm that there has been a shortage of staff in the past and this was one (1) of the reasons their medication was not being administered as prescribed on time. Residents also confirmed that the administering of medication is gotten better with the new staff but it still continues to be an issue. 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 AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20220127101012
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: 09/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2024
Section Cited
CCR
87465(a)(4)
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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:
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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 09/23/24
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Based on the observation, interviews and
record reviews, the licensee did not ensure 10 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.
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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 AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5