331880741-8-4-2022-18-AS-RRAZ-D9MPV6-20241001113838

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 08/04/2022
Date Signed: 08/04/2022 03:08:53 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/25/2022 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220725143537

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: 71	DATE:	08/04/2022
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Staff do not treat resident with dignity
Facility is not maintained in a clean state

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 allegations. The LPA met with Administrator, Kurt Niebres, and informed him of the purpose of the visit.

On this visit the LPA toured the facility, conducted staff/resident interviews, reviewed records and took copies of pertinent documentation.

Regarding the allegation, "Staff do not treat resident with dignity," it was alleged Staff One (S1) swears and yells at residents in care. Staff/resident interviews reported having had observations of S1 swearing and yelling at residents. S1 was interviewed and denied the allegation. The Administrator was interviewed and denied having any knowledge of the allegation. Therefore, based on interviews, this allegation is deemed SUBSTANTIATED. A citation will be issued.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220725143537

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ARLINGTON RIVERSIDE SENIOR COMMUNITY	FACILITY NUMBER: 331880741
	VISIT DATE: 08/04/2022

NARRATIVE

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Pertaining to the allegation, "Facility is not maintained in a clean state," it was alleged the medication room has trash and boxes everywhere, and there is staff food and candies lying around. An interview revealed trash, food packaging, food spillage, and scattered paperwork has been observed on several occasions in the medication room at the start of the morning shift. In addition, the LPA observed on August 02, 2022 there to be food spillage and food packaging on the floors of rooms 123 and 127. The LPA also observed soiled incontinence pads/diapers lying on the ground in room 127. Therefore, based on interview and observation, this allegation is deemed SUBSTANTIATED. A citation will be issued.

An exit interview was conducted with Niebres and a copy of this report was provided, along with LIC 811, Appeal Rights and Civil Penalties.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 18-AS-20220725143537

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 08/04/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/11/2022 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES: Residents in all RCFEs shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, & other persons. This requirement was not met, as evidenced by: Based on	1 2 3 4 5 6 7	The Administrator stated disciplinary action will be taken against S1 and in-service training provided.
	8 9 10 11 12 13 14	interviews the Licensee did not ensure residents were accorded dignity in their personal relationship with staff. Staff/resident interviews reported having had observations of S1 swearing and yelling at residents. This poses a potential threat to the personal rights of the residents in care.	8 9 10 11 12 13 14
Type B 08/08/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	MAINTENANCE AND OPERATION: The facility shall be clean, safe, sanitary & in good repair at all times...This requirement was not met, as evidenced by: Based on interview & observation, the licensee did not ensure the facility was clean. Interview revealed trash, food packaging, food spillage,	1 2 3 4 5 6 7	The Administrator stated a letter will be submitted to the Department certifying the areas were cleaned.
	8 9 10 11 12 13 14	& scattered paperwork has been observed in the med. room at the start of the shift. LPA observed food spillage & food packaging in rooms 123 & 127 & soiled incontinence pads/diapers lying on the ground in room 127. This poses a potential threat to the health, safety & personal rights of residents.	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: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC9099 (FAS) - (06/04)

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