331880741-1-26-2021-18-AS-NBRN-BXPPCW-20210128101234

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 01/26/2021
Date Signed: 01/26/2021 03:06:37 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 MS29-26
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/14/2020 and conducted by Evaluator Shaunte Henry

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200814144105

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: 64	DATE:	01/26/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Jenesa McDonald, Activity Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not ensure resident had access to Oxygen

INVESTIGATION FINDINGS:

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On 1/26/21 Licensing Program Analyst (LPA) Shaunte Henry conducted a tele-inspection due to COVID-19 in order to deliver the finding to the above allegations. LPA Henry spoke with Activity Director Jenesa McDonald and explained the purpose of the tele-inspection.

The investigation consisted of document review and interviews. The investigation revealed Resident 1 (R1) was without Oxygen for a period of time after the power outage on Sunday 8/9/20. This posed an immediate risk to the health and safety to R1.

Based on LPAs observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 1) is being cited on the attached LIC9099D.

An exit interview was conducted where the report, LIC 811 were discussed with and provided to Jenesa McDonald.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Edna Musoke	TELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200814144105

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 MS29-26
RIVERSIDE, CA 92507

FACILITY NAME: ARLINGTON RIVERSIDE SENIOR COMMUNITY	FACILITY NUMBER: 331880741
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/29/2021 Section Cited CCR 87611(1)(e)	1 2 3 4 5 6 7	87611 General Requirements for Allowable Health Conditions 87611(1)(e) In addition to Sections 87465(a) and 87464(d) the licensee shall ensure that the resident is cared for in accordance with the physician's orders and that the resident's medical needs are met.	1 2 3 4 5 6 7	The activity director has agreed to provide training to all caregivers on the administration of Oxygen and will submit proof of training to CCL by th POC date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: On 8/9/20 Resident 1 (R1) was without Oxygen for an extended period of time. This poses an immediate health and safety risk to the 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: Edna Musoke	TELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021

LIC9099 (FAS) - (06/04)

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