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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 11/05/2021
Date Signed: 11/05/2021 05:07:16 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: 54DATE:
11/05/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Kurt Niebres, ManagerTIME COMPLETED:
05:15 PM
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
Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to address violations observed during the investigation of ongoing complaints. The LPA was greeted by receptionist, Jasmine Singh, and met with Manager, Kurt Niebres. Niebres was informed of the purpose of the visit.

On November 04, 2021 and November 05, 2021 the LPA observed insufficient staffing in place at the facility. On November 04, 2021 the LPA observed Resident One (R1) to be requesting assistance from staff and had soiled themselves due to the wait time. A Situational Awareness and Response Assistant (SARA) revealed R1 waited more than thirty (30) minutes after pressing their pendent. Staff and resident interviews revealed the facility is insufficiently staffed. In addition, the LPA observed staff covering secondary job duties. Finally, a Personnel Report, dated November 05, 2021, indicates there are currently four (4) full time caregivers to assist fifty-four (54) residents. This poses an immediate health and safety risk to the residents in care. A citation and civil penalties will be issued.

On November 05, 2021, during the investigation of complaint #18-AS-20210901101814, the LPA observed no written report on file or submitted to the Department for Resident Two (R2) regarding a hospitalization. Records review was conducted and a Visit Summary Report revealed R1 was hospitalized for a fall on May 21, 2021. A citation will be issued.

An exit interview was conducted; this report was reviewed with Niebres and a copy provided along with Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2021
Section Cited

1
2
3
4
5
6
7
PERSONNEL REQUIREMENTS - GENERAL: Facility personnel shall...be sufficient in numbers...to provide the services necessary...This requirement wasn't met, as evidenced by: Based on interviews, observation & records, the Licensee did not ensure personnel were at all times sufficient in
8
9
10
11
12
13
14
numbers to provide the services necessary. R1 was observed requesting assistance, soiled themselves due to the wait. A SARA revealed R1 waited 30+ minutes. Interviews revealed the facility is insufficiently staffed. Staff are covering multiple job duties. An LIC500 indicates there are 4 full time caregivers.
8
9
10
11
12
13
14
Type B
11/26/2021
Section Cited

1
2
3
4
5
6
7
REPORTING REQUIREMENTS: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency regarding any of the events specified in (A)- (D) below. Any incident which threatens the
8
9
10
11
12
13
14
welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met, as evidenced by: Based on records review, the Licensee did not ensure a written report was submitted for R1.
8
9
10
11
12
13
14
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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2