331880741-5-17-2023-18-AS-RSTS-D9NM9F-20241002092434

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 05/17/2023
Date Signed: 05/17/2023 05:00:38 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
05/15/2023 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230515090143

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: 76	DATE:	05/17/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff are not preventing residents from smoking in the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to start the investigation into the above allegations. The LPA met with Kurt Niebres, Administrator, and informed him of the purpose for the visit.

A report was received by the Department alleging facility staff have not prevented residents from smoking indoors, where oxygen tanks are being utilized. Staff interviews reported there are residents who utilize oxygen tanks and a tour of the facility by the LPA confirmed this to be true. Staff interviews revealed multiple residents smoke inside the facility; it was reported residents have either been observed to be smoking inside their bedrooms or the smell of smoke can be observed in bedrooms and hallways. During the LPA's visit, the smell of cigarette smoke could be observed in hallways and resident bedrooms. The Administrator reported it is a house rule for residents not to smoke inside the facility and residents are given three warnings before being given an eviction notice. However, staff interviews revealed there were multiple observations of the same residents

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

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-20230515090143

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: 05/17/2023

NARRATIVE

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smoking inside the facility. Only one eviction notice was observed on file relating to a resident smoking inside the facility. Therefore, this allegation is deemed SUBSTANTIATED at this time. A finding that the complaint is substantiated means the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted; this report was reviewed with Niebres and a copy was provided, along with information on appeal rights.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20230515090143

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: 05/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/18/2023 Section Cited CCR 87618(b)(3)(C)	1 2 3 4 5 6 7	Oxygen Administration - Gas and Liquid: (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (C) Smoking shall be prohibited where oxygen is in use. This requirement was not met, as evidenced	1 2 3 4 5 6 7	The Administrator stated an updated copy of the facility's smoking policy will be submitted.
	8 9 10 11 12 13 14	by: Based on interviews and observation, the Licensee did not ensure smoking was being prohibited by the facility. Interviews and observation revealed there are residents utilizing oxygen tanks and there have been residents found to have been smoking inside the facility on multiple occasions.	8 9 10 11 12 13 14
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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: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC9099 (FAS) - (06/04)

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