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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 11/04/2021
Date Signed: 11/04/2021 03:50:37 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:
11/04/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Manager, Kurt NiebresTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to address deficiencies observed during the investigation of ongoing complaints. The LPA was greeted by receptionist, Jasmine Singh, and later met with Manager, Kurt Niebres. Niebres was informed of the purpose of the visit.

On November 04, 2021 the LPA did not observe waivers on file for Resident One (R1) or Two (R2). According to Niebres, no waivers were filed for R1 or R2. This poses a potential health risk to the residents in care. A citation will be issued.

On November 04, 2021, the LPA received information through interviews conducted, Staff One (S1) and Two (S2) conduct blood glucose tests for R1 and R2. R1 and R2 are both diagnosed with healthcare conditions requiring blood glucose testing. This poses a potential health risk to the residents in care. A citation will be issued.

On October 28, 2021 the LPA was informed by Niebres the facility did not have a complete Administrative Organization report on file. A copy of the organizational report was in turn requested by Niebres to maintain at the facility. This poses a potential safety risk to the residents in care. A citation will be issued.

LPA Torres attempted telephone interview with Licensee, Kevin Long Ha, however, he was unavailable at time of call. This report was reviewed with Manager, Kurt Niebres, and a copy was 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: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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 3
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: 11/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2021
Section Cited

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PLAN OF OPERATION: Each facility shall have & maintain a current, written definitive plan of operation. The plan & related materials shall be on file in the facility...The plan and related materials shall contain the following: Administrative organization. This requirement was not met, as evidenced by: Based on
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interviews, the Licensee did not ensure the facility's Administrator organization was maintained on file. According to staff, Kurt Niebres, no complete copy of the Administrative Organization was observed on file. This poses a potential safety risk to the residents 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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 11/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2021
Section Cited

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DIABETES: The licensee shall be permitted to accept/retain a resident who has diabetes if the resident is able to perform his/her own glucose testing...& is able to administer his/her own medication...or has it administered by an appropriately skilled professional. This requirement was not met, as evidenced by:
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Based on records & interviews, the Licensee did not ensure staff administer glucose testing were appropriately skilled professionals. Interviews reported S1 & S2 conduct blood glucose tests for R1 & R2, who are both dx with healthcare conditions requiring the testing.
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Type B
11/12/2021
Section Cited

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EXCEPTIONS FOR HEALTH CONDITIONS: As specified in Section 87209, the licensee may submit a written exception request if he/she agrees the resident has a prohibited &/or restrictive health condition but believes that the intent of the law can be met through alternative means. This requirement was not
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met as evidenced by: Based on records review and interview, the Licensee did not ensure a waiver request to retain R1 and R2 were submitted. Waiver requests for R1 or R2 were not observed on file. According to Niebres, no waivers were filed for R1 or R2.
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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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3