331880741-6-9-2021-18-AS-NBRN-C8LNC2-20211109092001

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 06/08/2021
Date Signed: 06/09/2021 07:47:53 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
03/01/2021 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210301133514

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	GEMMA DEOSO		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(951) 462-1025
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 57	DATE:	06/08/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Lori Matsushita, Executive Director		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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-Staff did not have resident's medical information readily available for responding emergency personnel.
-Staff did not follow resident's care plan.
-Staff did not administer resident prescribed medications
-Facility staff left residents unsupervised

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 information was obtained through reporting witnesses, interview of Administrator Gemma Deosso, review of facility records and medications and medication treatment records for R1. LPA additionally reviewed one (1) employee (S1) record and obtained copies of two hand written resident accounts (R2 and R3) of events occurring on 02/26/2021.

Based on information obtained during the course of this investigation through reporting witnesses and review of records the allegation that facility staff did not have resident's medical information readily available for responding emergency personnel is confirmed. LPA observed that R1's medication documentation and record were incomplete.

Substantiated

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: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

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 4

Control Number 18-AS-20210301133514

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: 06/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/09/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.	1 2 3 4 5 6 7	S1's employment was terminated on 02/26/2021. Inservice records for facility policy of attendance and responsibility for resident care and supervision.
	8 9 10 11 12 13 14	The facility failed to meet this requirement as evidenced by S1's termination for leaving the building on 02/26/2021. This poses a risk to the health and safety of residents in care.	8 9 10 11 12 13 14
Type A 06/09/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	The licensee shall assist residents with self-administered medications as needed. The facility failed to meet this requirement as evidenced by review of R1's medications revealed Furosemide	1 2 3 4 5 6 7	Medication audit was conducted. Medication Technician training review to be completed and inservice record submitted to CCL.
	8 9 10 11 12 13 14	medication in the bottle exceeded the quantity ordered.	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: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 18-AS-20210301133514

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: 06/08/2021

NARRATIVE

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This agency has found that the preponderance of evidence meets the standard and a violation has occurred.

In regard to the allegations of staff did not administer resident prescribed medications, and staff did not follow resident's care plan. LPA began medication order review for R1 with the medication Furosemide (LASIX) 20 mg Oral Tab. The directions read,"Take one tablet by mouth daily fdap (Flexible Diuretic Plan) if weight gain greater than 2 lbs in one day or by 5 lbs in one week or develops shortness of breath or swelling, take one additional tablet per day for 1 or 2 days). LPA first reviewed the medication administration records. LPA noted that for the month of February 2021, Monday through Friday there are no signatures for both the morning and evening doses. LPA then requested the centrally stored medication logs and noted that the current prescription filled on 10/09/2020 had not been logged on the centrally stored medication log. LPA observed that the medication quantity ordered was for 100 tablets. Next LPA looked at the medication bottle and observed what appeared to be more than 100 tablets in the bottle. LPA, with the assistance of facility administrator Gemma Deoso, counted the content of the medication bottle of Furosemide. The bottle contained 147 pills. Finally LPA requested record of the daily weights. A record was not produced. Blood sugar logs reviewed for December 2020 , January 2021, and February 2021 were incomplete. Blood sugar checks are ordered twice daily. Records for insulin administration were incomplete. This agency has found that the preponderance of evidence meets the standard and a violation has occurred.

It is alleged that facility staff left residents unsupervised. Based on interview with Gemma Deoso, S1 abandoned their shift leaving the facility unsupervised for which S1 was terminated of employment on 02/26/2021. Termination was based on resident reports of S1 leaving the building unsupervised. Hand written accounts of that even were obtained from two (2) residents. This agency has found that the preponderance of evidence meets the standard and a violation has occurred.

We have substantiated the complaint allegations A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. LPA Provided LIC 9099, 9099D, Appeal Rights, and LIC 811 during the exit interview.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20210301133514

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: 06/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/09/2021 Section Cited HSC 1569.618(b)(3)	1 2 3 4 5 6 7	At least one administrator, facility manager, or designated... The designated substitute shall meet qualifications that include, but are not limited to, all of the following: Training to effectively interact with emergency personnel in the event of an emergency call, including an ability to provide a resident’s medical records to emergency responders.	1 2 3 4 5 6 7	Licensee to update all designee training in the area of reporting to emergency responders by POC due date.
	8 9 10 11 12 13 14	The facility failed to meet this requirement as evidenced by information obtained through witness report and review of records being incomplete. This is a risk to the health and safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

LIC9099 (FAS) - (06/04)

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