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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 12/21/2021
Date Signed: 12/21/2021 02:58:43 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
07/24/2020 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200724143536
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: 59DATE:
12/21/2021
UNANNOUNCEDTIME BEGAN:
12:29 PM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff do not respond to call button in a timely manner
Facility is malodorous
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.

Regarding the allegation, "Staff do not respond to call button in a timely manner," it was alleged Residents One (R1) and Two (R2) utilized the facility call system around July 24, 2020 to obtain assistance in the restroom and no staff arrived for more than one hour. A Situational Awareness and Response Assistant (SARA) log was received and reviewed for the time period of July 10, 2020 through July 24, 2020. The records show the call system was utilized on July 10, 2020, July 14, 2020, and July 24, 2020, in which the response was not answered for approximately one (1) hour. The record also shows that on July 14, 2020 four (4) sequential calls were made with a wait time of approximately thirty (30) minutes each. Each call was made from the bedroom shared by R1 and R2. Furthermore, R1's Physician's Report, dated February 22, 2018, indicates the resident has no capacity for meeting their own toileting needs, while an Appraisal/Needs
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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 5
Control Number 18-AS-20200724143536
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: 12/21/2021
NARRATIVE
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and Services Plan, dated June 06, 2020, indicates the resident is a two person transfer, needs assistance with all Activities of Daily Living, and needs assistance with toileting. Staff/resident interviews were conducted. Administrator, Deborah Higgins, reported R1 and R2 were known to frequently utilize the call system for unnecessary assistance. R2 was interviewed and reported R1 has waited more than one (1) hour for staff when they needed assistance in the restroom. R1 was interviewed, acknowledged the alleged violation occurred and then later denied it. Additional staff interviews could not corroborate or refute the allegation occurred. Therefore, based on records and interview, this allegation is deemed SUBSTANTIATED because the preponderance of evidence standard has been met.

Pertaining to the allegation, "Facility is malodorous," it was alleged facility staff fail to take out the trash timely, which contain soiled diapers, and causes the facility to smell all day. It was observed, on March 25, 2021, a feces type of odor near the private dining room. A tour of the facility, in addition to staff interviews, revealed soiled adult diapers are thrown into the waste buckets in a storage space adjacent to the private dining room and are only taken outside of the facility at the end of the day. Therefore, based on observation and interviews, this allegation is deemed SUBSTANTIATED.

A finding that the complaint is substantiated means the allegations are valid because the preponderance of the evidence standard has been met. Citations will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted with Niebres; this report was reviewed, and a copy provided.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20200724143536
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: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2021
Section Cited
CCR
87411(a)
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PERSONNEL REQUIREMENTS-GENERAL: Facility personnel shall at all times be sufficient in numbers, & competent to provide the services necessary to meet resident needs...This requirement wasn't met, as evidenced by: Based on records & interviews, the Licensee didn't ensure personnel were
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The Administrator stated additional staffing will be provided and proof will be submitted to the Department by POC.
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sufficient in numbers to meet resident needs. Records show multiple calls were made from the room shared by R1 and R2, which were not answered for about 1 hr. Records indicate R1 needs assistance with toileting. R2 was interviewed & reported R1 has waited more than 1 hr for staff assistance.
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Type B
12/31/2021
Section Cited
CCR
87303(a)(1)
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MAINTENANCE AND OPERATION: The facility shall be clean, safe, sanitary & in good repair at all times...Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement was not met, as evidenced by: Based on observation & interviews,
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The Administrator stated a written statement will be provided to the Department by POC due date regarding change of location of trash bins.
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the Licensee did not ensure the facility kitchen areas were maintained in an odorless condition. LPA observed on 03/25/21, a feces type of odor near the private dining room. Interviews reported soiled adult diapers are thrown into the waste buckets in a storage space adjacent to the private dining room.
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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) 295-3927
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/21/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
07/24/2020 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200724143536

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: 58DATE:
12/21/2021
UNANNOUNCEDTIME BEGAN:
12:29 PM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
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9
Staff yell at residents
Residents' bathing needs are not being met
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 was greeted by Administrator, Kurt Niebres, and informed him of the purpose of the visit.

Regarding the allegation, "Staff yell at residents," it was alleged staff yelled at Resident Three (R3) around February 2020. LPA conducted interviews with (6) staff and (7) residents. R3 was interviewed and denied the allegation. Interviews could not corroborate or refute the violation took place. Therefore, based on a lack of information, this allegation is deemed UNSUBSTANTIATED at this time.

Pertaining to the allegation, "Residents' bathing needs are not being met," it was alleged R1 and R2 were not receiving assistance to bathe in two (2) to three (3) weeks. Records review provided no documentation of proof of bathing assistance to either R1 or R2. Staff/resident interviews could not corroborate or refute the violation took place. R1 and R2 were interviewed and could not recall if their bathing needs were being met or not during
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: 4 of 5
Control Number 18-AS-20200724143536
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: 12/21/2021
NARRATIVE
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this time. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.
A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

This report was reviewed with Niebres and a copy was provided.
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
LIC9099 (FAS) - (06/04)
Page: 5 of 5