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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 03/10/2022
Date Signed: 03/11/2022 04:19:59 PM


Document Has Been Signed on 03/11/2022 04:19 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: 67DATE:
03/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
11:22 AM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to address concerns observed during the ongoing investigation of complaints pending against the facility.

On March 10, 2022 LPA Torres observed two (2) occasions in which Staff One (S1) was yelling at residents in care. First, the LPA observed S1 yelling at Resident One (R1) who was refusing to be changed. S1 was heard making statements such as, "I do not care if you do not want me to change you, it's for your own good," and, "I do not care if you report me, I will report you". R1 was overheard telling S1 and others to leave her alone.

Secondly, S1 was observed to be showering Resident Two (R2) on this same day. R1 could be heard making statement's such as, "it's cold," and "I'm going to fall". S1 was heard yelling at the resident, saying, "no, you know it's not cold," and, "no, you're not going to fall". R2 could also be heard yelling, "ouch". A third party interview revealed S1 was very rude to the residents. It was reported R2 did not want to receive assistance to bathe. This poses a threat to the personal rights of the resident in care. Citations will be issued.

An exit interview was reviewed with Niebres, in which this report was reviewed and a copy was provided, along with the Appeal Rights.
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)
Page: 1 of 2


Document Has Been Signed on 03/11/2022 04:19 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: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2022
Section Cited

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PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: based on
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observation & interview, the Licensee did not ensure residents in care were accorded dignity in their personal relationships with staff. The LPA observed S1 yelling at R1 and R2 while assisting them with changing and bathing.
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Type B
03/18/2022
Section Cited

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ADDITIONAL PERSONAL RIGHTS OF RESIDENTS IN PRIVATELY OPERATED FACILITIES: ...residents in privately operated RCFEs shall have all of the following personal rights: To make choices concerning their daily lives in the facility. This requirement was not met as evidenced by: based on observation &
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interview, the Licensee did not ensure residents in care were given the right to make choices concerning their daily lives. R1 was overheard telling S1 & others to leave her alone. A third party interview revealed R2 did not want to receive assistance to bathe.
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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: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2