331880741-9-25-2021-18-AS-DMUN-CCRUPB-20220322154513

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 09/25/2021
Date Signed: 09/25/2021 12:17:24 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 COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	GEMMA DEOSO		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(951) 462-1025
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 52	DATE:	09/25/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident eloped from facility without staff knowledge

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 was met by receptionist, Jasmine Singh, and later me with Administrator, Kurt Niebres. Niebres was informed of the purpose of the visit.

Pertaining to the allegation, "Resident eloped from facility without staff knowledge," it was alleged that on January 05, 2021 around 10:00 PM Resident One (R1) had eloped from the facility, without staff knowledge, and became lost. The investigation was commenced on January 07, 2021. R1 was interviewed and did not recall whether the incident took place. Staff One (S1) who was allegedly on duty on January 05, 2021 could not be reached for an interview. Third party interviews were conducted, however, no eyewitnesses were found to provide a statement on the alleged incident. Therefore, due to a lack of information, 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. An exit interview was conducted with Niebres, in which this report was reviewed and a copy provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2021

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 2