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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 02/07/2022
Date Signed: 02/07/2022 06:30:28 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:KURT NIEBRESFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 66DATE:
02/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Kevin Long Ha, LicenseeTIME COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to address concerns reported regarding the facility's staffing. The LPA met with Licensee, Kevin Long Ha, and informed him of the purpose of the visit.

The LPA issued a citation on February 01, 2022 regarding lack of staffing. A Plan of Correction was agreed upon by Administrator, Kurt Niebres, to be submitted by February 04, 2022. No plan was received addressing the staffing of the facility. In addition, it was reported there was insufficient staff on February 06, 2022 and on February 07, 2022. The LPA followed up on the concerns on February 07, 2022 and observed there to be only one (1) caregiver and one (1) medication technician available. Interviews and records review revealed there to be insufficient staffing available on this date. A Civil Penalty will be issued.

Interviews revealed staff, who are not licensed professionals, are providing insulin injections to Resident Two (R2). The facility has been cited previously, on November 04, 2021, for non-licensed staff members giving injections to residents in care. A Citation and Civil Penalty will be issued. Interviews revealed Resident Twenty One (R21) has not received their insulin medication in approximately two (2) days. R21's medication list indicates the medication is to be given before each meal period. The Medication Administration Record (MAR) for R21 shows no log of insulin administered. A Citation will be issued. It was also reported there are seventeen (17) residents receiving Hospice services at this time. The facility currently has an approved waiver for eight hospice residents. No requests for hospice exceptions have been received from the facility. A citation will be issued. The LPA observed there to be no Written Record of Care on file for Resident Fourteen (R14) and Twenty (R20). Therefore, the LPA was unable to verify the care agreement made between the residents and the facility. A Citation will be issued.

An exit interview was conducted; this report was reviewed with Ha and a copy was provided, along with Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
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 4
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: 02/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2022
Section Cited

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INCIDENTAL MEDICAL AND DENTAL CARE:...facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions.
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This requirement is not met as evidenced by: Based on records review & interviews the Licensee did not ensure medication was given according to the physician's directions. Interviews and records review reveal R21 has not received their insulin medication in 2 days. This poses an immediate threat to the health of R21.
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Type B
02/14/2022
Section Cited

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HOSPICE CARE WAIVER: In order to accept or retain terminally ill residents & permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. This requirement was not met, as evidenced by: Based on records & interviews, the Licensee did not
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ensure a waiver was obstained. Records review & interviews revealed there are 17 residents receiving Hospice services. The facility currently has an approved waiver for 8. No requests for hospice exceptions have been received. This poses a potential threat to the health, safety and personal rights of 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) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 02/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/07/2022
Section Cited

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PERSONNEL REQUIREMENTS - GENERAL: Facility personnel shall...be sufficient in numbers...to provide the services necessary...This requirement wasn't met, as evidenced by: Based on interviews & records, the Licensee did not ensure personnel were at all times sufficient in numbers to provide the
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services necessary. Interviews reported staff were unable to assist residents with their daily needs due to insufficient staffing. A SARAfor 02/01/22 log revealed residents utilized the facility call system & not receiving assistance for at least 30 mins. This poses an immediate threat to the health of the residents in care.
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Type A
02/10/2022
Section Cited

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INJECTIONS: The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional. This requirement was not met, as evidenced by: Based on interviews, the Licensee did not
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ensure injections were administered by appropriately skilled professions. Interviews revealed staff, who are not licensed professionals, are providing injections to R2. This poses an immediate threat to the health of 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) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 02/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2022
Section Cited

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RESIDENT PARTICIPATION IN DECISIONMAKING: Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting...with any other appropriate parties, to prepare a written record of the care the resident will receive in the facility...This requirement was not met as evidenced by: Based on records
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review, the Licensee didn't ensure a written record of care was establised for residents in care. No Written Record of Care was observed on file for R14 & R20. This poses a potential threat to the health, safety, & personal rights of 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) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4