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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 02/15/2022
Date Signed: 02/15/2022 09:05:58 AM



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
08/04/2020 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200804151148
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:
02/15/2022
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Jenesa McDonald, Business Office ManagerTIME COMPLETED:
09:05 AM
ALLEGATION(S):
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Facility staff caused injury to 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 allegation. The LPA met with Business Office Manager, Jenesa McDonald, and informed her of the purpose of the visit.

Regarding the allegation, "Facility staff caused injury to resident," it was alleged that on or around August 01, 2020, Administrator Deborah Higgins, Staff One (S1) and Two (S2) pushed their way into Resident One's (R1's) bedroom, grabbed R1 and shoved them, resulting in a bruised arm and a swollen leg. Staff and resident interviews were conducted. Administrator Higgins denied the allegation, indicating R1 had assaulted S1 resulting in the staff requiring medical assistance. S1 and S2 were interviewed and denied the allegation. R1 was interviewed and reported the incident did take place and that they were injured as a result of the incident. Additionally, a video recording was received revealing an incident did take place in which S1 entered R1s bedroom without consent and confiscated R1s video camera. The recording shows R1 preventing S1 from
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: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022
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-20200804151148
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: 02/15/2022
NARRATIVE
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leaving their bedroom after the staff took possession of their property. As a result, S1 pushed past R1 causing the resident to stumble backwards slightly. Interviews also reported R1 was evaluated by a medical professional after the alleged incident. Medical records reviewed by the LPA revealed the resident was evaluated on July 28, 2020 for a leg injury. Procedure notes indicated no internal or exterior abnormalities were observed after the examination was conducted on the resident's right leg. No further injuries were noted in the records.

Based upon the investigation, the allegation that facility staff caused injury to resident could not be corroborated, therefore, 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 occurred.

This report was reviewed with Business Office Manager, Jenesa McDonald, and a copy was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 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
08/04/2020 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200804151148

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:
02/15/2022
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Jenesa McDonald, Business Office ManagerTIME COMPLETED:
09:05 AM
ALLEGATION(S):
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Facility staff removed resident's door.
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 allegation. The LPA met with Business Office Manager, Jenesa McDonald, and informed her of the purpose of the visit.

Regarding the allegation, "Facility staff removed resident's door," it was alleged facility staff, on or around August 01, 2020 removed the bedroom door of Resident One (R1). Staff and resident interviews were conducted. Interviews reported Staff One (S1) removed the bedroom door of R1 after the resident vandalized the door. A video recording obtained shows writing in black permanent marker on the door stating “after 10pm”. Administrator, Deborah Higgins, was interviewed and corroborated the allegation. She stated R1 was offered another bedroom, however they refused. She stated R1's door was put back on within two (2) days. R1 was interviewed and reported the bedroom door was removed as a tactic of harassment. Two (2) of the five (5) resident and staff interviewes reported the door was removed for approximately two (2) weeks. S1 was interview and reported having no knowledge of how long the door had been removed.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20200804151148
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: 02/15/2022
NARRATIVE
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Therefore, based on interviews conducted this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means the allegation is valid because the preponderance of the evidence standard has been met. A citation will be issued.

An exit interview was conducted with Business Office Manager, Jenesa McDonald in which this report was reviewed and a copy provided, along with LIC 811 and Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20200804151148
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: 02/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2022
Section Cited
CCR
87468.2(a)(1)
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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 have a reasonable level of personal privacy in accommodations...This requirement was not met as evidenced by: Based on
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R1's bedroom door has since been returned. R1 no longer resides at the facility. POC cleared.
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interviews the Licensee failed to ensure R1 was given a reasonable level of personal privacy. Interviews reported S1 removed the bedroom door of R1 & it was removed for approximately 2 weeks. This poses a potential threat to the personal rights of the resident 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: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5