331880741-9-27-2021-18-AS-DMUN-C9STVZ-20211217140442

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 09/25/2021
Date Signed: 09/27/2021 10:04:54 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
03/26/2020 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200326143953

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	HIGGINS, DEBORAH		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(714) 476-7777
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 52	DATE:	09/25/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff are not responding to call button

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to deliver the findings of the investigation on the above allegation. The LPA was met by Administrator, Kurt Niebres, and informed him of the purpose of the visit.

Regarding the allegation, "Staff are not responding to call button," it was alleged facility staff do not respond to the facility's signal system for several, unidentified, residents. The Depatment initiated the investigation on April 02, 2020; records were reviewed and copies obtained. Per Administrator, Deborah Higgins, staff were trained to respond to pull cords or pendents within five (5) minutes. A Situational Awareness and Response Assistant was reviewed for the time period of March 15, 2020 through March 26, 2020. The log revealed there were thirty-five (35) calls for assistance which were not responded to for more than thirthy (30) minutes. Through interviews it was revealed staff response times caused resident's immediate needs to be delayed. This posed an immediate threat to the health and safety of residents in care. Therefore, based on interviews and records review, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means the

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2021

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-20200326143953

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: 09/25/2021

NARRATIVE

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records received from the facility, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted with Administrator Deoso; this report was reviewed and a copy provided, along with LIC 9099D, LIC 811, and Appeal Rights.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

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
03/26/2020 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200326143953

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	HIGGINS, DEBORAH		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(714) 476-7777
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 52	DATE:	09/25/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff are failing to provide adequate food service

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to deliver the findings of the investigation on the above allegations. The LPA was met by receptionist Jasmine Singh and later met with Administrator, Kurt Niebles. Niebres was informed of the purpose of the visit.

Pertaining to the allegation, "Staff are failing to provide adequate food service," it was alleged residents in care are fed dried meat that is inedible, soup that is watery, and the kitchen runs out of items regularly. The Department initiated the investigation on April 02, 2020. Resident interviews were conducted; five (5) of the seven interviews conducted reported the quality of the food provided by the facility was well. No further information was received to cooroborate or refute the alleged violation took place. Therefore, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Niebres, in which this report was reviewed and a copy provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2021

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20200326143953

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: 09/25/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/28/2021 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, & competent to provide services necessary to meet resident needs. This requirement was not met as evidenced by: Based on interview & records review, the Licensee did not ensure personnel were at all	1 2 3 4 5 6 7	The Administrator stated proof of in-service training regarding response times will be submitted to the Depatment.
	8 9 10 11 12 13 14	times sufficient...to meet resident needs. A Situational Awareness & Response Assistant report was reviewed, which revealed 35 calls for assistance were not responded to for 30+ mins. Interview revealed staff response times caused resident's immediate needs to be delayed.	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) 202-5776
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4