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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 11/10/2021
Date Signed: 11/10/2021 02:23:10 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:
11/10/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Jannessa McDonald, Business Office ManagerTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to conduct a health and safety inspection in relation to complaint #18-AS-20211110104308. The LPA was greeted by receptionist, Jasmine Singh, and met with Business Office Manager, Janessa McDonald. McDonald was informed of the purpsoe of the visit.

The LPA conducted staff and resident interviews. Three (3) of seven (7) reports were received regarding a staff member being rough with residents. Additional information could not be provided at time of visit. Additional investigation will be conducted and citation issued if required. No immediate health and safety concerns were reported.

This report was reviewed with McDonald and a copy was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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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