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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 04/27/2021
Date Signed: 04/27/2021 03:33:59 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
01/05/2021 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210105091009
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: 58DATE:
04/27/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility did not ensure that medications are properly stored
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to deliver findings on the above allegation. The LPA was greeted by Business Office Manager, Jenesa McDonald, and granted entrance into the facility. The LPA spoke with Administrator, Kurt Niebres, and informed him of the purpose of her visit.

Pertaining to the allegation, "Facility did not ensure that medications are properly stored," it was alleged facility staff delivered a box of medications to Resident One's (R1's) bedroom on or around December 20, 2020. LPA, Susan Parker, initiated the investigation on January 07, 2021; she conducted an interview with Administrator, Gemma Deoso. Deoso reported medications were delivered to R1's bedroom accidentally by Staff One (S1) and returned by the resident on December 27, 2020. R1 was interviewed and reported medications were delivered to their bedroom and were returned to staff handling medications. S1 was interviewed and stated they could not recall if they delivered a box of medications to R1's bedroom. Records review was conducted; a Physician's Report for Residential Care Facility for the Elderly (RCFE) revealed the resident is unable to manage their own medication. This posed a potential risk to the resident in care. Therefore, based on interviews, this allegation is deemed SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
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 3
Control Number 18-AS-20210105091009
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: 04/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2021
Section Cited
CCR
87465(h)(2)
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Incidental Medical & Dental Care: The following requirements shall apply to meds which are centrally stored: Centrally stored meds shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not
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The Administrator stated proof of in-service training on medication delivery procedures will be submitted to the Department by POC due date.
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met as evidenced by: Based on interviews, the Licensee did not ensure R1's meds were kept inaccessible to unauthorized individuals. Deoso reported meds were delivered to R1's bedroom accidentally by S1 & returned by the resident on 12/27/20. R1 reported meds were delivered to their bedroom and were returned to staff.
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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: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20210105091009
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: 04/27/2021
NARRATIVE
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A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

This report was reviewed with Niebres and a copy provided.

SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3