331880741-2-26-2021-18-AS-NBRN-BYLUHN-20210226143612

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 02/25/2021
Date Signed: 02/26/2021 08:49:15 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
06/02/2020 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200602141522

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	HIGGINS, DEBORAH		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(951) 462-1025
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 63	DATE:	02/25/2021
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Gemma Deoso, Administrator		TIME COMPLETED:	08:45 AM

ALLEGATION(S):

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Staff is verbally abusive to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Goldenberg is conducting a visit to conclude this agency's investigation into the complaint allegations noted above. LPA met with Gemma Deoso, Administrator and discussed the findings of the investigation conducted and written by LPA Susan Parker below.

"The investigation consisted of the following: LPA Parker interviewed residents #1, 2, 3, 4, 5, 6 and #7, staff #1, former administrator Deborah Higgins, and LPA Parker received a copy of a receipt for repair of the dishwasher. The investigation revealed the following: In early June 2020 there was some exchange of words in the dining room at lunch time. Residents #1 and #4 said they heard staff #1 call resident #1 a name. Residents #2, #3, #5, #6 and #7 were in the immediate vicinity, and they said they did not hear staff #1 call resident #1 a name.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200602141522

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: 02/25/2021

NARRATIVE

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Resident #6 said staff #1 never called resident #1 a name, and that it was resident #7 who called the name. LPA spoke with resident #7 and this resident admitted to calling resident #1 the name which was heard by others. LPA spoke with staff #1 and this staff denied calling resident #1 a name.

Although the allegation may have happened, there is not a preponderance of evidence to prove the allegation occurred, therefore the allegation is Unsubstantiated."

LPA Goldeneberg reviewed this report with Ms. Deoso and a copy of this report was provided to her.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2021

LIC9099 (FAS) - (06/04)

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