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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 02/25/2022
Date Signed: 02/25/2022 03:28:34 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 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/05/2020 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200805132424
FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 66DATE:
02/25/2022
UNANNOUNCEDTIME BEGAN:
02:27 PM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff are not administering resident's medication per physician orders
Facility staff are not notifying responsible party about health changes
Facility staff are intimidating resident
Facility staff yell at resident
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 into the above allegations. The LPA met with Administrator, Kurt Niebres, and informed him of the purpose of the visit.

Pertaining to the allegation, "Facility staff are not administering resident's medication per physician orders," it was alleged facility staff refused to provide Resident One's (R1's) medications and, when administered, were provide at the wrong times. The investigation was initiated on August 13, 2020; staff/resident interviews were conducted. Staff One (S1), who was identified as one of the individuals who had dispensed R1's medication incorrectly, could not be reached for an interview. R1 was interviewed and reported staff had administered their medication incorrectly several months ago, however, it has not occurred recently. A date of the alleged incident could not be identified through interviews. An audit of R1's medications could not be completed due to the medication no longer being available at the time of the investigation. Administrator Deoso was interviewed and
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
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 2
Control Number 18-AS-20200805132424
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: 02/25/2022
NARRATIVE
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denied the allegation. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time.

With regard to the allegation, "Facility staff are not notifying responsible party about health changes," it was alleged facility staff are not reporting concerns/inquiries relating to R1's mental health to the resident's responsible party. Administrator Deoso was interviewed and confirmed they had suggested a mental health evaluation for R1, however, they had not ordered one without the approval of R1's authorized representative. R1 was interviewed and reported facility staff do report concerns regarding R1's health to their responsible party. R1 reported having no knowledge of undergoing a mental health evaluation following a request by the Administrator. Interviews could not corroborate or refute the allegations occurred. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time.

With regard to the allegation, "Facility staff are intimidating resident," it was alleged Administrator, Deborah Higgins, Staff One (S1), and Staff Two (S2) informed R1 they were going to be moved out of their bedroom because they were not paying enough for the one they currently occupied. R1 was interviewed and report no concerns of staff threatening to remove the resident from their bedroom because they did not pay more in rent. Administrator Higgins was interviewed and denied the allegation. Additional staff interviews could not be conducted. Therefore, due to a lack of information this allegation is deemed UNSUBSTANTIATED at this time.

Pertaining to the allegation, "Facility staff yell at resident," it was alleged R1 was yelled at by S2 to pay them $300 which was owed for having a pet in their bedroom. R1 was interviewed and corroborated the allegation. S2 was interviewed and denied the allegation. Therefore, due to a lack of information, 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(s) occurred.

This report was reviewed with Niebres and a copy 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
LIC9099 (FAS) - (06/04)
Page: 2 of 2