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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 03/18/2022
Date Signed: 03/18/2022 03:39:32 PM


Document Has Been Signed on 03/18/2022 03:39 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: 62DATE:
03/18/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to address violations observed during the investigation of ongoing complaints. The LPA met with Administrator, Kurt Niebres, and informed him of the purpose of her visit.

On this visit the LPA toured the facility and obtained information on current non-ambulatory residents in care. The LPA was informed on March 08, 2022 by the local fire department of the requirement for the facility not to place non-ambulatory residents on the second floor, though they had been observed on previous visits (March 15, 2022; March 11, 2022; March 10, 2022; February 24, 2022; and February 25, 2022). Through records review it was revealed the facility's approved fire clearance did not provide details of this requirement. Administrator Niebres agreed to establish a plan to ensure the facility remains in compliance with the fire clearance.

On February 24, 2022 the LPA observed Staff One (S1) checking the blood glucose of Resident One (R1). The LPA instructed S1 to discontinue the test, due to the individual not being an appropriately skilled professional, and informed Administrator Niebres of the occurrence. Niebres confirmed S1 was not an appropriately skilled professional. A citation will be issued.

On February 17, 2022 the LPA was informed of concerns relating to the lack of activities provided by the facility for the residents in care. The LPA observed on multiple visits (March 15, 2022; March 11, 2022; March 10, 2022; February 24, 2022; and February 25, 2022) there to be no activities available for residents. Staff and resident interviews reported no activities were being made available. A citation will be issued.

An exit interview was conducted; this report was reviewed with Niebres and a copy was provided, along with Civil Penalties and Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
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 2


Document Has Been Signed on 03/18/2022 03:39 PM - It Cannot Be Edited

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: 03/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2022
Section Cited

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DIABETES: The licensee shall be permitted to accept/retain a resident who has diabetes if the resident is able to perform their own glucose testing..., or has it administered by an appropriately skilled professional. This requirement was not met, as evidenced by: Based on observation and interview the
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licensee did not ensure R1 performed their own glucose testing or had it administered by an appropriately skilled professional. On 02/24/22 S1 was observed checking the blood glucose of R1. The Administrator confirmed S1 was not an appropriately skilled professional. This poses a potential threat to R1's health & safety.
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Type B
03/25/2022
Section Cited

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PLANNED ACTIVITIES: Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. This requirement was not met, as evdenced by: Based on observation and interviews, the Licensee did not ensure there was
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opportunity for resident participation in planned activities. The LPA observed on multiple visits there to be no activities available for residents. Staff & resident interviews reported no activities were being made available. This poses a potential threat to the health & 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: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2