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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 09/28/2021
Date Signed: 11/05/2021 02:22:27 PM



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
09/18/2020 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200918123327
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: 52DATE:
09/28/2021
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Kurt NiebresTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Facililty not assisting resident with medications.
INVESTIGATION FINDINGS:
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This unannounced visit conducted by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegations mentioned above.

During the course of the investigation, interviews were conducted with staff, a review of resident records (R1) was completed, and copies of pertinent documents were obtained. Through review of the record and interviews LPA learned the following: In regard to the allegation of facility not assisting resident with medication, review of resident admission agreement reveals that R1 moved in to Arlington Riverside Senior Community on 08/21/2020. Interviews of staff and resident indicated that R1 did not receive medication from admission through November 2020. According to interview of the facility administrator on 09/23/2020 R1's medications were stored in the medication room and not dispensed without a physician order. A review of R1's record revealed that there were no medication orders on file for September and October 2020 supporting what interviews revealed.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 18-AS-20200918123327
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2021
Section Cited
CCR
87465(a)(5)
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Incidental Medical and Dental Care: The licensee shall assist residents with self-administered medications as needed. The facility failed to meet this requirement as evidenced
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Administrator agrees to review admission procedures with medication technicians to include assuring incoming residents continue to receive their medications uninterrupted
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by interviews and review of R1's record, R1 did not receive medication for two months because the facility failed to obtain medication orders from a physician for R1's medication timely. This poses a risk to the health and safety of residents in care.
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and that physician's orders are on file for all incoming medications. Policy and procedure training record to be provided.
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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: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20200918123327
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: 09/28/2021
NARRATIVE
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We have substantiated the complaint allegation as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5