331880741-9-25-2024-18-AS-TDAN-D9FUU6-20240925155257

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 09/25/2024
Date Signed: 09/25/2024 01:53:35 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 Martinez

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:	0	CENSUS: 0	DATE:	09/25/2024
		UNANNOUNCED	TIME BEGAN:	08:41 AM
MET WITH:			TIME COMPLETED:	08:42 AM

ALLEGATION(S):

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Staff failed to meet resident’s needs
Staff failed to respond to call button

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 facility staff neglected to address pus coming out of Resident One's (R1's) stoma and leg on or around 01/16/2023. The investigation included staff and resident interviews, records review, and records collection. R1 was interviewed and confirmed they do have colostomy and a leg wound for which their medical provider is addressing. On 01/31/2023 the LPA observed the resident's two (2) conditions to be covered and or bandaged up. R1 reported facility staff were not assisting them with waking up in the morning to get ready to be transported to their medical appointments where they could obtain treatment. R1 also reported there were times in which they declined to attend their medical appointment. A review of records failed to indicate the facility was responsible for waking R1 up for appointments. According to a representative of R1's medical provider, the resident was supposed to have three visits, weekly, at their clinic

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: 09/25/2024

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 3

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
	VISIT DATE: 09/25/2024

NARRATIVE

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to provide care for the resident's leg wound. Administrator Niebres was interviewed and reported R1 has slept in and has missed transportation to their appointment. Review of a Communication Log, dated 01/16/23, written by Tammy Chavez (Wellness Director), R1's stoma was observed to be red with excoriated skin surrounding the area, with no drainage. The note continued to describe the mouth of the stoma as pink. Yet there was no evidence the facility arranged for R1 to be seen by a doctor to address this concern. The review of records did not uncover evidence of any documentation of the facility's plan to supervise and address R1's health condition. R1 was later admitted to a local Skilled Nursing Facility (SNF) in March 2023. This violation posed a potential threat to the health, safety, and personal rights of the resident in care. Therefore, based on interviews and records, this allegation is deemed SUBSTANTIATED.

Another allegation was received by the Department alleging the facility staff do not answer the call system utilized by residents in care. Six (6) out of seven (7) resident interviews revealed staff do not answer resident's calls for assistance; however, specific information on those instances could not be provided. Staff interviews were conducted; two (2) out of two (2) staff member reported the call system was working and calls were being answered. One staff member reported there were times in which one resident, after being assisted by staff, would quickly call again and/or claim they accidentally used the pull cord and did not need the assistance. One (1) witness interview revealed staff did not answer the call system for at least one hour when assistance was needed for a resident care. In addition, a review of call logs from 01/16/2023 through 01/20/2023 revealed two (2) residents, on more than one occasion, waited more than 30 minutes for staff assistance when they used the call system. This violation posed a potential threat to the health, safety, and personal rights of the residents in care. Therefore; based on interviews and records, this allegation is deemed SUBSTANTIATED.

A finding that the complaint is substantiated means that the allegations are 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: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 09/25/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/25/2024 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to...Section 87468.1, residents in...RCFEs shall have all of the following...rights: (4) To care, supervision, & services that meet their...needs... This requirement was not met, as evidenced by: Based on interviews &	1 2 3 4 5 6 7	R1 no longer resides at the facility. This facility ceased operations on April 17, 2024.
	8 9 10 11 12 13 14	records, the licensee didn't ensure R1's was afforded the right to care, supervision, & services to meet their needs. R1 reported staff were not assisting them with preparing for their appointments. A communication log revealed R1's stoma was observed red with excoriated skin surrounding the area...	8 9 10 11 12 13 14
Type B 09/25/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requirement was not met, as evidenced by: Based on interviews and records, facility personnel were insufficient in	1 2 3 4 5 6 7	R1 no longer resides at the facility. This facility ceased operations on April 17, 2024.
	8 9 10 11 12 13 14	numbers to meet resident's needs. 6 out of 7 resident interviews revealed staff do not answer resident's calls for assistance...Call logs from 01/16/2023 - 01/20/2023 revealed 1 resident waited more than 30 minutes for staff assistance.	8 9 10 11 12 13 14

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: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC9099 (FAS) - (06/04)

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