331880741-8-9-2021-18-AS-NBRN-C6EMC9-20210831092906

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 08/04/2021
Date Signed: 08/09/2021 10:20:13 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/16/2020 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200316112148

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	HIGGINS, DEBORAH		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(714) 476-7777
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 55	DATE:	08/04/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not ensure that resident was adequately fed.
Staff did not address resident's medical needs in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Goldenberg is conducting this unannounced visit to conclude this agency's investigation into the allegations noted above.

During the course of this investigation LPAs conducted interviews, reviewed (R1's) resident record and obtained copies the of admission agreement, Identification and Emergency Information, physician's report, preplacement appraisal, monthly task sheet and resident notes. LPA learned the following information: R1 lived at the facility from 12/31/2019 through 5/25/2020 according to resident notes reviewed. Physicans report dated12/18/2019 notes that R1 is able to feed themself, however, interview revealed that staff do assist R1 during meals and that they come down to the dining room to eat. Interviews revealed that R1 passed away in 2020. It is alleged that staff will leave food out of reach of the client and not come back to check on him for hours. Interviews conducted did not reveal any corroborating witness to the allegation that staff did not ensure that resident was adequately fed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

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-20200316112148

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 COMMUNITY	FACILITY NUMBER: 331880741
	VISIT DATE: 08/04/2021

NARRATIVE

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In regard to the allegation that staff did not address R1's medical needs in a timely manner, the information available through interviews did not reveal details of an incident where staff did not address R1's medical needs in a timely manner.

Based on the available information we have found the complaint allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

LIC9099 (FAS) - (06/04)

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