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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 02:44:23 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
10/11/2022 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 18-AS-20221011121440
FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:KURT NIEBRESFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:0CENSUS: 102DATE:
09/21/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Molly BowieTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not seek medical attention for resident in a timely manner.
Staff did not ensure resident was provided prescribed medications.
Staff did not ensure resident's room was clean and sanitary.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Gina Saucedo and Michael Cava conducted a subsequent visit to the facility to conclude the investigation regarding the above allegations. The ten day visit was made by LPA Stephanie Torres on 10/17/22. 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 was also conducted.

Staff did not seek medical attention for resident in a timely manner:
In regards to the allegation, it was reported that on or about 10/05/22, Resident 1 (R1) was experieincing some pain to their right arm, but staff did not assist R1 when they were complaining of pain. R1's responsible person had to contact another adult day care health program, who had to call 911 to get R1 immediate medical attention. Interviews with R1's responsible person and another state agency confirm
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 4
Control Number 18-AS-20221011121440
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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someone with the adult day health program called 911 to have R1 transferred to the hospital, where they were placed on ICU for a blood clot. If that call was not made, R1 could have expired. On 09/21/24, LPAs Saucedo and Cava interviewed five (5) residents, who stated there is a lack of staffing that can call for immediate medical attention in a timely manner when needed. Based on the information obtained, the allegation of staff not seeking medical attention for a timely manner is Substantiated.

Staff did not ensure resident was provided prescribed medications:
In regards to the allegation, it was reported that when R1 was transferred to the facility from a Skilled Nursing Facility (SNF), their medications was not transferred to the facility with them. Facility staff did not assist in retrieving R1's medications from the SNF. As a result R1 was not taking any of their medicine since admission. Interviews with R1's responsible person and another state agency confirm that the facility never retrieved R1's medications from the SNF, leaving R1 without their medications for 5 days. On 09/21/24, LPAs Saucedo and Cava interviewed an additional five (5) residents. Three of these five residents stated that that the facility staff had failed to provide them their prescribed medication in a timely manner. Based on the information obtained, the allegation of staff not ensuring residents were provided their prescribed medications is Substantiated.

Staff did not ensure resident's room was clean and sanitary:
In regards to the allegation, it was reported that R1's room was observed cobwebs, stains and urine smell to the carpet and insects in the bathroom. On 10/17/22, LPA Torres conducted the ten day visit to the facility to investigate the allegation. During the visit, LPA Torres observed a stained carpet; cob webs, dust, and debre in the sliding door tracks of R1's room. A cockroach was also observed in the shower of R1's bathroom. Based on the observation by LPA Torres, the allegation is Substantiated.

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 4
Control Number 18-AS-20221011121440
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
87465(g)
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Incidental Medical and Dental Care- The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health. This requirement was not met as evidenced by: an interview with another state agency and another state agency confirming that
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Facility has since closed on 04/15/24. No corrections required at this time.
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the facility staff did not call 911 for immediate medical when R1 was complaining of pain to their right arm. R1 was eventually sent to the hospital and admitted for a blood clot. This posed an immediate health and safety risk to the resident in care
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Type A
09/21/2024
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care- The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Interviews with R1's responsible person and another state agency confirm that the facility never retrieved R1's medication from
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Facility has since closed on 04/15/24. No corrections required at this time.
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the SNF where R1 was residing prior, leaving R1 without their medications for 5 days.
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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 4
Control Number 18-AS-20221011121440
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
87303(a)
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Maintenance and Operation- The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: During their visit on 10/17/22, LPA Torres observed observed a stained carpet; cob webs, dust, and debre in the sliding door tracks of R1's room.
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Facility has since closed on 04/15/24. No corrections required at this time.
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A cockroach was also observed in the shower of R1's bathroom. This posed an immediate health and safety risk to the resident 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: 4 of 4