<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 09/21/2024
Date Signed: 10/04/2024 11:14:14 AM

Unsubstantiated


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
12/05/2023 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 18-AS-20231205160513
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 Bowie - AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not allow a resident to access their bedroom

Staff did not treat resident with dignity
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This report is amended to rectify typographical error. No change in findings.
Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with Administrator, Molly Bowie and explained the reason for the visit.

LPA conducted a physical plant tour at around 9:50 AM, requested copies of facility documents relevant to the investigation at 10:15 AM and interviewed staff and residents between 10:15 AM to 11:15 AM. Regarding the allegation that staff did not allow a resident to access their bedroom, it was alleged that Resident #1 (R1) came from the hospital and arrived at the facility at around midnight of 11/12/23 and staff wouldn't allow R1 to get to R1's room. LPA Martinez's interview with five (5) staff on 12/07/23 between 9:42 AM to 4:26 PM revealed that no one among the five (5) staff interviewed witnessed any staff not allowing R1 to get into R1's room. Further, two (2) of the staff who was with R1 during the incident on 11/12/23 denied refusing to allow R1 to get into R1's room. (continued LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
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 2
Control Number 18-AS-20231205160513
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(continued from LIC 9099)

Regarding the allegation that staff did not treat resident with dignity, it was alleged that during the incident on 11/12/23, staff were yelling at R1, and Staff #1 (S1) bumped R1’s shoulder intentionally (no injuries reported). LPA Martinez's interview with two (2) staff present during the incident on 12/07/23, revealed that it was actually R1 who did the yelling and not the staff. LPA Martinez's interview with two (2) additional staff confirmed that S1 and Staff #2 (S2) were with R1 during the incident but did not yell at R1. Further interview with S1 also revealed that they did not bump into R1's shoulder, nor did they have any knowledge of what was being alleged by R1. LPA Martinez's interview with the former administrator on 12/07/23 at around 12:25 PM also revealed that the administrator did not receive any report regarding any incident about R1. LPA's interview with ten (10) residents today between 10:15 AM to 11:15 AM revealed that ten (10) out of ten (10) residents stated that staff are respectful and treat them well.

Based on the information gathered this and prior visit, these allegations are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

Due to the facility closure on April 15, 2024, a copy of this report and the appeal rights (LIC 9058) will be sent via email to Adam Zenou at Adam@skilledmanagementco.com and another certified copy vis USPS to Mr. Zenou’s at the his last known address.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
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 2