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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 02/25/2022
Date Signed: 02/25/2022 03:13:54 PM


Document Has Been Signed on 02/25/2022 03:13 PM - It Cannot Be Edited

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:
02/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:27 AM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility on February 24, 2022 to initiate the investigation into complaint #18-AS-20220215121707. Following the closure of the complaint visit, the LPA was made aware of concerns regarding the hot water temperature on the second floor of the building.

The LPA returned to the facility on this date and measured the temperature of the water in several rooms on the second floor. None of the rooms had a hot water temperature measuring between 105 and 120, however, upon the LPA's arrival to the facility a Plummer was observed on the premises. According to a representative of the plumming company additional time is required to continue the needed maintenance and will return on February 26, 2022. No citations were issued due to the facility taking immediate action.

This report was reviewed with Administrator, Kurt Niebres, and a copy was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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