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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 08/24/2021
Date Signed: 08/24/2021 03:44:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:GEMMA DEOSOFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 53DATE:
08/24/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jenesa McDonald, Business Office ManagerTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Amy Goldenberg arrived to the facility unannounced to conduct a case management visit. The purpose of this visit is to gather additional details regarding a potential health and safety concern discovered during a complaint investigation at this location. LPA observed on 08/23/2021 that room number 227 had a towel under the doorway and a sign reporting to not enter. LPA inquired as to the reason and learned that the resident had been relocated due to bug concerns, but was unable to obtain additional information on the issue that date. Today LPA met with Janesa and learned the following information: Something was biting the resident (R1) residing in the room. It has not been determined what was causing the bites. This facility has implemented a plan to address this issue already. The facility has already relocated the resident and isolated the room. R1's personal possessions are inside room number 227. An appointment with Terminex exterminators has already been scheduled for 08/30/2021 to determine a course of action to eradicate any potential pest problems. Terminex was contacted in LPA presence to confirm scheduled visit. Jenesa has agreed to provided LPA with a copy of the visit and the plan implemented by Terminex following the visit on 08/30/2021.

As the facility has already implemented a course of action on this concern, based on the information received, there are no deficiencies being cited at this time.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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