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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 04/19/2022
Date Signed: 04/19/2022 03:47:18 PM


Document Has Been Signed on 04/19/2022 03:47 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: 64DATE:
04/19/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Stephanie Torres and Chinwe Nwogene, conducted an unannounced visit to the facility to address a violation observed during the investigation of ongoing open complaints. The LPAs met with Administrator, Kurt Niebres, and informed him of the purpose of the visit.

On March 08, 2022, the Department was made aware the facility's Fire Clearance did not address limitations specific to non-ambulatory residents remaining on the first floor only. The facility put a plan in place on March 21, 2022 in order to relocate all non-ambulatory residents from the second floor to the first. On April 15, 2022, Administrator Niebres informed the LPA all non-ambulatory residents had been moved from the second floor to the first.

On April 15, 2022 LPA Torres observed Resident One (R1) to be residing on the second floor in bedroom 239. Interview and observation revealed R1 does require the use of a wheelchair. This poses a threat to the health and safety of the resident in care. A citation and civil penalty will be issued.

Due to the Administrator not being available for the conclusion of the visit, an exit interview was conducted with Business Office Manager (BOM), Jenesa McDonald, and a copy was provided, along with Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/19/2022 03:47 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: 04/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2022
Section Cited

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FIRE SAFETY: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met, as evidenced by: Based on observation, the Licensee did not ensure the facility was
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maintained in conformity with the regulations adopted by the State Fire Marshal. On 04/15/22 LPA Torres observed R1 to be residing on the 2nd floor in bedroom 239. Interview & observation revealed R1 does require the use of a wheelchair.
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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: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
LIC809 (FAS) - (06/04)
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