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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 12/17/2021
Date Signed: 12/17/2021 04:00:41 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: 58DATE:
12/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to address violations observed during the investigation of ongoing complaints. The LPA met with Administrator, Kurt Niebres, and informed him of the purpose of the visit.

During the investigation of complaint #18-AS-20211022122606, interviews revealed no staff providing food service are trained as a nutritionist, a dietitian, or a home economist. It was also revealed no consultant regularly visits the facility who is trained as a nutritionist, a dietitian, or a home economist. This poses a potential health and safety risk to the residents in care. A citation will be issued.

During the initiation of complaint #18-AS-20211110104308, and other complaint investigations, staff/resident interviews reported no activities are provided to residents & the assigned activity director is assisting with other tasks. This poses a potential personal rights risk to residents in care. A citation will be issued.

During a visit, in relation to complaint #18-AS-20211115143027, S1 was observed to be working at the facility on 12/13/2021. S1 does not have an active California background clearance. This poses a potential threat to the residents in care. A citation will be issued.

This report was reviewed with Licensee, Kevin Long Ha, over the phone and with Niebres in person.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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: 12/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/24/2021
Section Cited

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General Food Service Requirements: The following food service requirements shall apply: In facilities licensed for 50 or more, & providing 3 meals per day, provision shall be made for regular consultation from a person who is a nutritionist, a dietitian, or a home economist. This requirement was not met, as
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evidence by: Based on interviews the Licensee didn't ensure a qualified consultant was regularly providing services to the facility. This poses a potential health, safety, and personal rights risk to the residents in care.
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Type B
12/31/2021
Section Cited

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Planned Activities: In facilities licensed for 50 persons or more, 1 staff member shall have full-time responsibility to organize, conduct & evaluate planned activities...This requirement wasn't met, as evidenced by: Based on
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interviews, the Licensee didn't ensure a staff member had full-time responsibility for activities. Interviews reported no activities are provided to residents & the assigned activity director is assisting with other tasks. This poses a potential personal rights risk to 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: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2021
LIC809 (FAS) - (06/04)
Page: 3 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: 12/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2021
Section Cited

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Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department...
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This requirement was not met as evidenced by: Based on records review, S1 is not fingerprint cleared to work at the facility. S1 was observed to be working at the facility on 12/13/2021. S1 does not have an active California background clearance. This poses a potential threat 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: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3