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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 09/21/2024
Date Signed: 09/21/2024 02:43:16 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
04/08/2024 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 18-AS-20240408164653
FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:WILLIAMS, MORGAN EFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:0CENSUS: 102DATE:
09/21/2024
UNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Molly BowieTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility is not adequately staffed resulting in residents not being provided care and supervision.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Gina Saucedo and Michael Cava conducted a subsequent complaint visit to the facility to conclude the investigation regarding the above allegation. The ten day visit was made by LPA Jacqueline Ross on 04/15/24. During today's visit, LPA Cava met with the Executive Director, Molly Bowie, and advised her of the allegation. Investigations held by LPAs Ross, Saucedo and Cava consisted of interviews with staff and residents, a physical plant inspection, and record review.

Facility is not adequately staffed resulting in residents not being provided care and supervision:
In regards to the allegation, it was reported that on or around 2/14/2024 to about 4/8/2024, the facility’s PM and night shifts have not had adequate staffing. There are nights when there is only one staff to provide care and supervision to approximately twenty-eight (28) residents. Calls also cannot get answered promptly, resulting in residents to wander and sometimes fall. On 04/15/24, LPA Ross interviewed five residents, of which three (3) of the five state there is a lack of supervision, causing a concern to their peers
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
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
Control Number 18-AS-20240408164653
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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of their needs not being met. Furthermore, there were at least two (2) residents who stated that when their call button was activated to request for help, there is a delay in response, or sometimes, there was no response at all. Moreover, on 04/15/24, LPA Ross tested the pull chord/or call button in a resident's room. From about 11:35am to 11:45am there was no response within those ten minutes. Four additional residents were interviewed by LPAs Saucedo and Cava during their investigation on 09/21/24. These residents stated they were still at the facility under the previous owner. These residents further revealed that there was insufficient staff at the facility at that time. In addition to resident interviews, LPA Ross interviewed three (3) staff during their investigation on 04/15/24. One (1) of the three staff revealed that there is a shortage of staff. Two additional staff, who were interviewed by LPAs Saucedo and Cava during their investigation on 09/21/24 stated it has gotten better, but adds that they had to come during the weekends to help assist with staffing.

Based on the information obtained, the allegation is Substantiated. Citation issued on the 9099D.

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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
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: 2 of 5
Control Number 18-AS-20240408164653
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
09/21/2024
Section Cited
CCR
87411(a)
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Personnel Requirements- 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: Interviews with reisdents and staff made on 04/15/24 & 09/21/24 reveal the facility had a shortage
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Facility has since closed on 04/15/24. No corrections required at this time.
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of staff. Interviews from residents indicated that there was no staff response when their call button was utilized. Moreover, on 04/15/24, when the call system was tested, there was no staff response. This posed an immediate health and safety risk to the residents 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
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: 3 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
04/08/2024 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 18-AS-20240408164653

FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:WILLIAMS, MORGAN EFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:0CENSUS: 102DATE:
09/21/2024
UNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Molly BowieTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Facility staff do not administer residents' medications as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Gina Saucedo and Michael Cava conducted a subsequent complaint visit to the facility to conclude the investigation regarding the above allegation. The ten day visit was made by LPA Jacqueline Ross on 04/15/24. During today's visit, LPA Cava met with the Executive Director, Molly Bowie, and advised her of the allegation. Investigations held by LPAs Ross, Saucedo and Cava consisted of interviews with staff and residents, a physical plant inspection, and record review.

Facility staff do not administer residents' medications as prescribed:
In regards to the allegation, it was reported that MedTechs are often behind hours administering resident medication. On 04/15/24, LPA Ross interviewed five residents. Three (3) of the five residents expressed no complaints about not getting their medications as prescribed adding they get their medicine within a timely manner of when it is supposed to be taken. On 09/21/24, LPAs Saucedo and Cava conducted interviews
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
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: 4 of 5
Control Number 18-AS-20240408164653
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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with five (5) additional residents, who deny the allegation, stating they get their medicine within an hour of when it was supposed to be taken. Based on the information obtained, there was insufficient evidence to corroborate the above allegation of residents not getting their medications as prescribed. Therefore, the allegation is deemed Unsubstantiated at this time.

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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
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: 5 of 5