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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 01/28/2021
Date Signed: 02/11/2021 01:26:15 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 MS29-26
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: 64DATE:
01/28/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Jenesa McDonald, Activity DirectorTIME COMPLETED:
04:45 PM
NARRATIVE
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On 1/28/21 Licensing Program Analyst (LPA) Shaunte Henry conducted a tele-inspection due to COVID-19 in order to present additional allegations in conjunction with complaint # 18-AS-20210128101519. The additional allegations are: 1) Staff did not allow visitations 2) Ombudsman poster not posted in facility. LPA Henry met with Activity Director Jenesa McDonald and explained the purpose of the tele-inspection. The investigation into the additional allegations consisted of document review, observation and interviews.

Allegation 1:

Documentation review revealed the family of Resident 1 (R1) were notified that they could not visit R1 due to COVID-19. According to PIN 20-23: facilities must allow visitation for medically necessary visits (e.g. end-of-life) or other urgent health or legal matters that cannot be postponed (e.g. estate planning, advance healthcare directives, Power of Attorney, transfer of property title, etc). R1 was receiving end-of life hospice services.

Based on LPAs observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8) is being cited on the attached LIC809D.

Allegation 2:

LPAs observation revealed the facility does have a large, encased Long Term Care Ombudsman poster hanging on the wall of the facility.

Although the above allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted where this report, LIC 809D and LIC 811 were discussed with and provided to Jenesa McDonald.

SUPERVISOR'S NAME: Edna MusokeTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021
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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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 MS29-26
RIVERSIDE, CA 92507

FACILITY NAME: ARLINGTON RIVERSIDE SENIOR COMMUNITY
FACILITY NUMBER: 331880741
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/05/2021
Section Cited

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87468.1(a)(11) PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidenced by:
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Based on document review and interviews, the facility failed to allow Resident 1 (R1) to have family visit while on hospice during the COVID-19 epidemic. This poses a potential threat to the personal right of 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: Edna MusokeTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2021
LIC809 (FAS) - (06/04)
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